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ORDER FORM Name Email Address Street Address City State Zip Code Work Phone Home Phone Shadowbox You're Interested In None Internal $145 Laser Internal $165 Corner $140 Laser Corner $160 Double Corner $180 Laser Double Corner $200 3 Section $150 Laser 3 Section $170 Lasered Ships Wheel w/ Flagcase $325Lasered Ships Wheel w/o Flagcase $250 Sea Chest You're Interested In None Shadowbox Top Sea Chest $650 CPO Sea Chest $800 Sword Chest $1000 Flag Case You're Interested In None Flag Case Desk Laser Burial Flag Case Jeff's Burial Flag CaseMemorials Gift or Accessory You're Interested In None Retirement Coin custom engraved $6 each 3X5 Flag $28 Liberty Coin $10 Saddam Coin $10 Iraq Pewter Coin $10 Iraq Bronze Coin $10 Sept 11 WTC Coin $10 CPO Coin $4 CPO Coin with Name/Date on reverse $7 Service Disc USCG $5 Service Disc USN $5 Service Disc USMC $5 Service Disc USAF $5 Service Disc Army $5 MCPON Herdt Coin $10 Background Fabric Choices Dark Blue Velveteen Red Velveteen Black Velveteen Woodland Camouflage Date Product Required/ Not Ceremony Date (Example: 31 Dec 05) Wood Type Preferred Red Oak Cherry (Add $20) Black Walnut (Add $15) Honduras Mahogany (Add $20) Laser Box Top Text: Laser Box Bottom Text:
Name Email Address Street Address City
Zip Code
Work Phone
Home Phone
Gift or Accessory You're Interested In None Retirement Coin custom engraved $6 each 3X5 Flag $28 Liberty Coin $10 Saddam Coin $10 Iraq Pewter Coin $10 Iraq Bronze Coin $10 Sept 11 WTC Coin $10 CPO Coin $4 CPO Coin with Name/Date on reverse $7 Service Disc USCG $5 Service Disc USN $5 Service Disc USMC $5 Service Disc USAF $5 Service Disc Army $5 MCPON Herdt Coin $10
Background Fabric Choices Dark Blue Velveteen Red Velveteen Black Velveteen Woodland Camouflage
Date Product Required/ Not Ceremony Date (Example: 31 Dec 05)
Wood Type Preferred
Red Oak
Cherry (Add $20)
Black Walnut (Add $15)
Honduras Mahogany (Add $20)
Laser Box Top Text:
Laser Box Bottom Text:
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