Please print this page and fill out completely. Use it to keep track of what you want to order.

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NOTE: Please add sales tax if you live in IOWA				.
.Plus Iowa Sales Tax 5.75%				.
.	.	.	TOTAL:	$
*Note: If price includes "Shipping" the charges are only within the USA. Call or for International charges or special handling (Priority Mail, etc). Thanks.. For International Shoe size conversion chart, go here.

Please ship to: Name:________________________________________________ Address:______________________________________________ . . . . . _______________________________________________ City:______________________ State: _____ Zip:_____________ Phone: ( _________________________) -- We will call or email you if we have questions. Email: ________________________________________________ I have enclosed a cashier's check or money order _______ , payable to Jewels by Jan. NO PERSONAL CHECKS, PLEASE Mail completed form to: Jewels by Jan 1930 NW 82nd Street Clive, IA 50325

Please allow 1-2 weeks for Delivery. // Questions about your order? Call Jan at (858) 414-4519

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http://www.jewels-by-jan.com/orderform.htm

page updated 04/03/07