MyPatchPlaque.com Mousepad & Coaster Order Form
(Please print this page and fill out the 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 photograph or patch and payment.  Remember, the quality of your mousepad or coaster set is directly related to the quality of the patch or photograph that you send in with your order.  Please specify the color of background you wish to use if ordering a patch or vehicle mousepad.

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 individual's name)  
Your patch or photograph will be returned with your completed order. 

ORDER QUANTITY AND PRICING
Choose background color if not using entire picture
Black
 Royal Blue
 Burgundy
 Navy Blue
 Gray
 Forrest Green
 Red		 mousepad(s)
 mousepad(s)
 mousepad(s)
 mousepad(s)
 mousepad(s)
 mousepad(s)
 mousepad(s)		 coaster set(s)
 coaster set(s)
 coaster set(s)
 coaster set(s)
 coaster set(s)
 coaster set(s)
 coaster set(s)

               Total of mousepad(s) and/or coaster set(s)at $15.00 ea

 = $

Oklahoma orders add 7.5% sales tax 

 = $

Shipping charges ($1.50 for 1st mousepad or set of coasters,
$1.00 for each additional mousepad or set of coasters    (add after tax) 

 = $
(additional charges apply for outside continental USA shipments, please call for pricing) Total   = $

Use the layout below to indicate any text or location of images for custom layouts (see web site)

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 MyPatchPlaque.com)

Referral Code:

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

MyPatchPlaque.com
P.O. Box 23111
Warr Acres, Oklahoma 73123

If you have any questions about your order, contact us at support@mypatchplaque.com
or by phone at (405) 834-0008