Date ________________                                                                        

Customer Name _____________________ *             

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



Rough-out - $440 _____

Basket Stamped - $550 _____

Floral Tooled - $650 _____



Sewn-on Fringe - Yes _____ (add $25)
                                    No  _____

Underlays - Yes _____ (add $25)
                           No _____
If yes, indicate underlay color _________________

Dual Fringe - Yes _____ (add $35)
                            No _____
If yes, color of 2nd fringe layer: _______________

Tooled back belt - Yes _____ (add $50)
                                        No _____

Tooled Corner Plates - Yes _____ (add $25)
                                                No _____

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




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










Body Color ____________________

Fringe Color (sewn on fringe) ___________________






Dyed - Yes _____ (add $15)
                No _____
If yes, indicate color: Black _____  Mahogany _____
                                            Cordovan _____

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

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

Basket Stamped back belt - Yes _____ (add $25)
                                                         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