Date ________________                                                                        

Customer Name _____________________ *             

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



Plain - $110 _____

Basket Stamped - $135 _____

Floral Tooled - $165 _____


Options:

Filigree - Yes _____ (add $25)
                    No _____
If yes, indicate filigree color __________________


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

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

Adjustable Strap - Yes _____(add $25)
                                        No _____

Clasp - Yes _____ (add $15)
                No _____

Pockets - 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











Two piece _____     Three piece _____

Width __________     Height __________

Thickness ___________

Strap Length __________



Liner color _______________



Dyed - Yes _____ (add $25)
                No _____
If yes, indicate color: Black _____  Mahogany _____
                                            Cordovan _____

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








~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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