THE SCOUT IMAGE
2063 S. HELLMAN AVE., SUITE C, ONTARIO, CA 91761 Voice: (909) 947-6634
Fax: (909) 947-6666 e-Mail:  tsi@TheScoutImage.com     http://www.ScoutPlaques.com
NAME  MEANING  PLAQUE  ORDER  FORM


ORDER  FORM  INSTRUCTIONS
1.Enter today's Date.       7. Enter the person's Birthdate.    
2.Enter your Background Paper choice.    8.Enter the person's Eagle Date (if applicable).
3.Select Plaque color.*      9. Total your order.
4. Fill in Date plaque is needed by.    10.Fill in your contact information.
5.Enter your Troop # and Council Name.    11. Fill in payment information.
6. Enter the person's First Name.   12. Print Form.
*Some background papers look better in Walnut, some in Black Marble.
If you prefer, we can choose the best plaque color for your background paper choice.
Use your browser's "Print" feature to print this form, sign it, and Fax or mail it to the address above.

Please do NOT send Credit Card information via eMail.


          Poem Plaque                       $ 24.95 Each
Shipping and Handling       $ 10.00

California Residents add 7.75% Sales Tax

PLAQUE  INFORMATION
Order Date:   - -
Background Paper:  
Select plaque color:  
Date plaque is needed by:   - -
Troop Number:  
Council Name:  
Personalization Information for Plaque
First Name:
Birthdate: - -
Eagle Date: - -






* * * * * * * * * * * * * * * * * * * * * * * *





ORDER   SUMMARY
  Poem Plaque  @  $ 24.95  =  $ 24.95
  California Sales Tax*   @    7.75%    =   $   1.93
  Shiping & Handling   @  $ 10.00  = $ 10.00
  Total    = 
* California Residents only

Billing Address
Parent's Name
Address 1
Address 2
City
State
Zip
Home Phone
- - 		Cell/Work Phone
- -
E-Mail
Shipping Address (if different)
Parent's Name
Address 1
Address 2
City
State
Zip
Phone
- -
We must have a phone number for the shipping address.



PAYMENT   INFORMATION:
 Check Enclosed
 Please charge my Credit Card
CREDIT  CARD   INFORMATION:
Name on Credit Card:
First NameMiddle NameLast Name
Please make sure that the Billing Address (above) is where the credit card statement is sent.
  Credit Card Type:     
CREDIT   CARD   NUMBER: EXPIRATION   DATE
        
Signature: _____________________________________________________


Click here to return to Name Meaning Plaque.
Click here to return to Order Forms Menu page.