Date ________________                                                                        

Customer Name _____________________ *             

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


Base Price

Plain - $6/each - Number wanted ______

Basket Stamped - $11/each - Number wanted _____

Floral Tooled - $16/each - Number wanted _____

Options

Dyed - Yes _____ (add $5/each)
                No _____

Filigree - Yes _____ (add $5/each)
                    No _____

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

Brand/Initials - Yes _____ (add $5/each)
                                   No _____


~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Total (# wanted x 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


















Dye Color: Black _____     Mahogany ______
                        Cordovan _____


Filigree 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