MyPatchPlaque.com Mousepad and Coaster Order Form

INSTRUCTIONS
Please fill out the form, click the print button at the bottom or the print button in your browser and then send it to us.  Be sure to include your patch and payment.  Remember, the quality of your mousepad or coaster is directly related to the quality of the patch or photograph that you send in with your order.  A new patch will provide the best plaque.  Colors of the reproduced patch may vary slightly.  Please specify the color of the background you wish to use if ordering if your photo or image does not cover the entire mousepad or coaster.

GRAPHIC INFORMATION

Enter the description of the patch, photograph or section of photograph you wish to be used in your mousepad or coaster sets.  Use the diagram below to indicate where you want the image placed and any text that you wish to have added to the item.  There is no additional charge for customizing each mousepad such as adding an officer's name or for recognition awards. Example: police car only, entire picture, add department name, or officer's name here
 (Example: Crooked Oak Police Department)  
Your patch or photograph will be returned with your completed order.

ORDER QUANTITY AND PRICING
Choose background color if image does not cover entire mousepad or coaster
Black mouspad(s)      coaster set(s)

Royal Blue mouspad(s)      coaster set(s)
Burgundy mouspad(s)      coaster set(s)
Navy Blue mouspad(s)      coaster set(s)
Gray mouspad(s)      coaster set(s)
Forrest Green mouspad(s)      coaster set(s)
Red mouspad(s)      coaster set(s)
Other __________ mouspad(s)      coaster set(s)
                       Total of:   mouspad(s)   + coaster set(s)

@ $15 each        =$

Oklahoma orders add 8.5% sales tax = $

Shipping charges ($1.50 for 1st mousepad or set, $1.00 for each additional (add after tax) = $
(additional charges apply for outside continental USA shipments, please call to arrange)
  Total  = $
 

Use the layout below to indicate any text or location of images for custom layouts

SHIPPING INFORMATION
Name:
Address/Suite or Apt.
City: State:     Zip:
Phone (Days): Phone(Other):
Email address:

BILLING INFORMATION (Only for department orders with pre-approval and purchase order)
Contact: Agency:
Address/Suite or Apt:
City:State:Zip:
Phone (Days): Phone(Other):
Email address:
PAYMENT METHOD:   Check or Money Order PO#
                 For Credit Cards Use    Paypal (send to paypal ID [email protected])

Referral Code:

Please send your patch or other image, this completed order form, and your payment to:

MyPatchPlaque.com, P.O. Box 850555, Yukon, OK 73085-0555

If you have any questions about your order, contact us at [email protected]
or by phone at (405) 834-0008