Order Form

Order Form - Please fill out and mail with payment to:
Marilyn R. Diener Originals, P.O. Box 6014, Wyomissing, PA 19610 USA

Shipped to:
Name:___________________________________
Address:___________________________________
City:___________________________________
State/Providence:______________________Zip:_____________
Country:___________________________________
Phone (In Case I Have a Question)__________________________
Wedding or Birth Certificates, please attach forms.
Date of Order ____/____/____

Quantity Item# Description Price Each Total

Shipping Charges Rush Charge

15% of total Order ($3.00 Minimum) Subtotal

Note Cards $3.50 per 3 packs for shipping Tax (PA 6%)

PA Residents add 6% Sales Tax Shipping

Total Due

Method of Payment
____Check or Money Order enclosed
____Credit Card
(Select One) ____AMX ____VISA ____ MC ____Disc
Card Number___________________________________
Expiration Date ____/____/___
Signature (required)________________________________

All artwork is an original and may vary some what from original shown, each piece is unique, but similar.
Please allow 4 to 6 weeks (unless otherwise indicated) for completion and delivery,
if needed before allotted time, please add $15.00 rush charge to order.

Official Use Only
Date Received ___/___/___
Date Shipped ___/___/___

Order Information

Quantity	Item#	Description	Price Each	Total





		Shipping Charges	Rush Charge
		15% of total Order ($3.00 Minimum)	Subtotal
		Note Cards $3.50 per 3 packs for shipping	Tax (PA 6%)
		PA Residents add 6% Sales Tax	Shipping
			Total Due

Official Use Only
Date Received	___/___/___
Date Shipped	___/___/___