First Name                Last Name    

Organization Name

Mailing Address   

City                               State       Zip Code

Telephone Number        Fax Number

Email Address      

Please describe the product, or products, you wish to purchase. Also indicate the design you would like to have embroidered. For example, "I would like to purchase quilt lined jackets for a trucking fleet with a company logo embroidered on the back, and individual names embroidered on the front." 

Please indicate whether or not you have a custom design created for your art work. Thank you.