ORDER FORMS

8750 GEORGIA AVE
SUITE 1218A
SILVER SPRING,MARYLAND
20910

IN MEMORY OF
ORDER FORM

NAME:_________________________________

ADDRESS:_________________________________

CITY:_________________________________

STATE:__________ZIP:____________

PHONE:(_ _ _) _ _ _ - _ _ _ _

ORDERS

ITEM NAME:_________________________________

ITEM DISCRIPTION:_________________________________

_________________________________________________________

NUMBER ORDERED:_____________

SIZE: __Full Screen: $100.00 __Half Screen: $75.00

PRICE $:______x___= $__________

ITEM NAME:_________________________________

ITEM DISCRIPTION:_________________________________

__________________________________________

NUMBER ORDERED:_________

SIZE: __Full Screen: $100.00 __Half Screen: $75.00

PRICE $:______x___= $_______

New Memorials are placed on web site at the begining of each month.

In item discription, place person name, dates, and city and state of birth.

memorials are never removed from web page unless stated other wise.

Payment are one time payments,

Sorry we can not accept credit cards, credit card services we be available in near furture.

Make checks and/or money orders payable to : jrs black inc
and mail to address above.

IN MEMORY OF ORDER FORM

IN MEMORY OF
ORDER FORM