PLAQUE ORDER FORM

First Name:	*
Last Name:	*
Email address:	*
Phone Number:	*
Address 1:	*
Address 2:
City:	*
State:	*	- - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code :	*
911 Plaque ($50.00 ea.) Type in quantity:
Customized Plaques ($60.00 ea.) Type in quantity:
Photo Upload (For customized plaques)	* JPEG, Tiff or PDF photo accepted. 300 dpi. The larger the picture, the better.
Poem # (Click on View Our Poems) on Plaque Home Page or type in your own poem in the field below.
Your Own Poem Wording
Plaque Color:	*	Choose One Medium Oak Mahogany Blue Marble Black Marble Green Marble Ruby Marble White Marble
Engraved Plate Color	*	Gold-Toned Plate Silver-Toned Plate
Engraved Wording (Limited to 20 Characters)	*
Questions and Comments. Also, use this section when ordering multiple plaques to indicate which poem and photo goes with which color plaque and engraved plate.
Tax (6%)	*
Total