MyPatchPlaque.com 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 MyPatchPlaque is directly related to the quality of the patch that you send in with your order.  A new patch will provide the best plaque.  Colors of the reproduced patch may vary slightly.  Finished sizes vary depending on the shape of the patch used.

PATCH INFORMATION
Enter the description of the patch that you would like made into a plaque:
 (Example: Crooked Oak Police Department)  

ORDER QUANTITY AND PRICING

Total of standard plaque(s) at $25.00 each

 = $
Total of large plaque(s) at $40.00 each = $

Oklahoma orders add 8.5% sales tax 

 = $
Shipping charges ($5.00 for 1st plaque, $3.00 for each additional plaque) add after tax  = $
(additional charges apply for outside continental USA shipments, please call for pricing) Total   = $

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, 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