Order Form

Personalized Coin - order form
Print this form , complete all information, and fax to 623-266-7318 or print and mail to: coinable.com - 20783 N 83rd Ave, Suite 103-484, Peoria, AZ 85382

Quantity of coins: ______________ Each coin: $16.99 + shipping via USPS Priority, no markup on shipping!

#______________ Dead Mans Hand (New Style with just the hand)
                                      1.56 inch, Antique Silver, one side color

#______________ Dead Mans Hand (Old Style with the skeleton)
                                      1.56 inch, Antique Silver, one side color

#______________ Donkey (Don't Be The Ass)
                                      1.56 inch, Antique Silver, one side color

#______________ River Rat (Up The River Without A Paddle)
                                      1.56 inch Antique Silver, one side photographic printing

#______________ Suited (But they were suited, but were you suited to win)
                                      1.56 inch Antique Bronze, one side color

#______________ Suited (But they were suited, but were you suited to win)
                                      1.56 inch Antique Bronze, one side color

#______________ Common-Silver
                                      1.56 inch Antique Silver, one side color

#______________ Common-Bronze
                                      1.56 inch Antique Bronze, one side color

#______________ Heart Shaped
                                      2 inch Nickel, one side transparent paint and epoxy

#______________ Diamond Shaped
                                      2 inch Nickel, one side transparent paint and epoxy

#______________ Club Shaped
                                      2 inch Nickel, one side transparent paint and epoxy

#______________ Spade Shaped
                                      2 inch Nickel, one side transparent paint and epoxy

FONT: (serif_____, sans serif_____, square serif_____)

Customer ID________________________________ (assigned by inscribable.com)      We accept :AMEX / VISA/ Master Card/ IMPAC

____ New Order   ____ Reorder           Amount Being Charged:$______________       Promo Code:_______________________________

ORDER TYPE: ____ REGULAR w/sample coin (with more than 25 coins)          ____ REGULAR, NO sample coin           ____ RUSH ORDER (additional fees apply)

Credit card#:

Exp Date:

Name on card: ___________________________________________________          LINE #1:___________________________________________________

Billing address: __________________________________________________          LINE #2:___________________________________________________

                                      __________________________________________________         LINE #3: ___________________________________________________

                                      __________________________________________________

Shipping Address: (POC) __________________________________________________          BLIND ____

                                                                (Same?___) __________________________________________________

                                                                 __________________________________________________

Telephone Number: (day)_____________________________ ( ____ evening or ____ cell)_____________________________

e-mail address for receipt of payment:, only one email per line

____________________________________________________________________________

e-mail address for artwork approval: (Same?____ )

____________________________________________________________________________

By signing this order form, you certify that you are authorized to sign the debit or credit card listed above, that you have read and agree with the terms of service as listed on our web page at http://www.inscibable.com/tos.html, that you agree to have the above credit or debit card charged for the merchandise placed by this order, and if applicable, all artwork, cancellation and die fees as explained more fully in the terms of service.

Signature:_________________________________ Printed name:_________________________________ Date:___________________
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