Andersen Jewelry Design

8010-A Highway 9

Ben Lomond , CA 95005

(831)336-3525

Fax: (831)336-3005

Alan@AndersenJewelry.com

Custom designs and special orders priced as negotiated with Alan.

(all orders shipped to billing address only)

Billing Name: _____________________________________________

Billing Address: _____________________________________________

City, State: _____________________________________________

Zip, Country: _____________________________________________

Billing Phone Number: _____________________________________________

Credit Card Type:

Visa ___ Matercard ___ all American Express ___

Diners Club ___ Carte Blanche___ JCB___

Card Number: ___________________________________________________

Expiration Date: ___________________________________________________

Print Name: ____________________________________________________

Sign Name: ____________________________________________________

Date: ____________________________________________________

California Residents Tax 8.00% $_____________

Overnight Mail & Insurance add $15.00 $_____________

Priority Mail add $4.00 $_____________

Insurance & Handling

($200 or less: $5.00, $201 to $500: $8.00) $_____________

Total $_____________

(Purchaser is responsible for reporting any district use tax.)

Use area below for detailed description of purchase