SPECIAL PURPOSE STAMP ORDER FORM

	First Name:
	Last Name:
	Company Name:
	Address:
	City:
	State/Prov:
	Country:
	Zip/Postal Code
	Phone:
	Email:
	Special Purpose Stamp Required:	Special Purpose Selection Pen Stamp 512 010 00 - 8 mm x 33 mm #1 Rubber Pencil Cap - 12 mm #2 Rubber Pencil Cap - 17 mm Pre-Inked Pencil Cap - 13 mm Round Pre-Inked Pencil Cap - 19 mm Round #63 Pre-Inked Inspection Stamp - 18 mm x 18 mm #69 Pre-Inked Inspection Stamp - 22 mm Round #0 Dural Pocket - 12 mm Round #1 Dural Pocket - 19 mm Round #2 Independent - 11 mm x 39 mm #1 Hercules Pocket - 14 mm x 56 mm #2 Hercules Pocket - 25 mm x 57 mm SIGN TRONIC - 1/8" Electonic Type
		.
		Text to be on the Stamp
	1st Line: {where applicable}
	2nd Line: {where applicable}
	3rd Line: {where applicable}
	4th Line: {where applicable}
	Additional Information:
	Alignment: {where applicable}	. Centered Please Indicate Left Justified Right Justified Fully Justified
	Border: {where applicable}	Yes No Please Indicate
	Font Settings: {where applicable}	ALL UPPER CASE Please Indicate Upper & Lower Case
	If text does not clearly fit selected stamp...	Upgrade to a Larger Stamp Please Indicate Decrease Font Size to fit Stamp chosen
	Quantity:
	Stamp Pad Color: {where applicable}	Dry Please Indicate Inked - Black Inked - Red Inked - Blue Inked - Green
		.
		Indicate Font Style

If Different Font Required, Please Advise your Font Choice(s):
	.
Cardholder Name:
Credit Card Type:	VISA	MasterCard
Credit Card Number:
Expiration Date:
Shipping:	Please Indicate Prepay & Charge Collect
	Choose one of the Following Regular - Ground Rush - Overnight 2nd Day
Courier of Choice: