300 Cherry Street
Roaring Spring, PA 16673
814.224.5570
814.224.1288 fax

Customer name:

 

Address: (we need a street address for shipping UPS)

 

 

 

Phone:

Chap color:

Smooth out

Suede out
Chap leather:

Special instructions:

 

 

 

Date needed:

Deposit with this order:

Payment method

Check

Credit card

Credit card number:

Expiration date:

Name as it appears on card:

Signature for credit card payments:

Billing address if different from shipping address:

 

 

 

For deposits made by credit card, we will bill the balance due plus shipping charges to your card upon completion of your order unless you direct us to do otherwise.