Date ________________                                                                        

Customer Name _____________________ *             

Street # or PO Box ___________________ *
                        
                             City ___________________ *
                      
                           State ___________________ *
 
                  Zip Code ___________________ *


Base Price:

Plain- $33 ______

Basket Stamp - $55 _____

Floral Stamped - $66 _____


Options:

Filigree - Yes _____ (add $15)
                     No _____
If yes, indicate filigree color ___________________


Initials/Brand - Yes ______ (add $15)
                                   No ______

Silver - Yes _____ (add $6 each piece)
                  No _____

Pear Shading - Yes _____ (add $10)
                                No _____

Clasp - Yes _____ (add $15)
                No _____


~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Total (base price + all options) _______________

Due with order (50% of total) _______________

Due on completion (remaining 50%) _______________

Or Payment in Full _______________

Phone number (___)______________ *

                 E-mail __________________

  * indicates a required field




















Dyed - Yes _____ (add $15)
               No _____
Dye Color  Black _____ Mahogany _____
                    Cordovan _____

Card Slots - Yes _____ (add $10)
                          No _____

Pen Holder - Yes _____ (add $5)
                             No _____

Liner Color ____________________







~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Print this page, mark desired options and send with cashier's check
 or postal money order for the amount at left to:

Empire Leather Company
Brett Buchanan, Maker
PO Box 262
Durkee, OR 97905