My Dad's Inspirations Order Form

Please print this form out and mail with your check or money order to:

Please print neatly:

Name: ___________________________________________

Street Address: _____________________________________

City: _____________ State: ____________ Zip: ___________

Address Number Blocks: ($2.50 Each) Print the Number you want here :___________________

Number Color (select one): Hunter Green [__] Burgundy [__] Liberty Blue [__]

Design Block: ($2.75 Each) order one for each season

[__] Apple [__] Sunflower [__] Heart [__] Flag [__] Pumpkins [__] Christmas Wreath

Holders:

7in x 9in 3 Block (3 Numbers or 2 Numbers and 1 Design) $7.00 [__] Apples [__] Hearts

7in x 12in 4 Block (4 Numbers or 3 Numbers and 1 Design) $8.00 [__] Apples [__] Hearts

7in x 15in 5 Block (5 Numbers or 4 Numbers and 1 Design) $9.00 [__] Apples [__] Hearts

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Total From Above $__________________

Shipping & Handeling +$3.95

Gift Wrap Optional ($2.00) ____________

WV Residents 6.5% Tax ______________

Total Enclosed $_____________________

Make Checks Payable To:

My Dad's Inspirations
48 Chapel Road,
Wheeling, WV 26003

Shipping Address (if different)

Name: ___________________________________________

Street Address: _____________________________________

City: _____________ State: ____________ Zip: ___________

If gift please notify us with any special instructions:

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Gift Card Note: ______________________________________________________________

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