Patchwerkes, L L C.
P O Box 841
Newton KS 67114-0841
Voice & FAX: (800) 657-1722
E-mail:sales@patchwerkes.com

ORDER FORM
Order No. ______________	Date __________________
Ship to: ______________________________	Bill to: ______________________________
_______________________________	______________________________
_______________________________	______________________________
Quantity: ___________	Date Needed: ______________________
Size:    [_]as sample      [_]as sketch	[_]to be ___ " round  [_]to be ____" by ____"
Correct Spelling: ________________________	________________________
Background:   [_]fully embroidered	[_]twill color:__________________
Border Color: _________________	[_]merrowed      [_]cut border
Design Colors (don't forget the lettering)
1. __________ for	_______________________________
2. __________ for	_______________________________
3. __________ for	_______________________________
4. __________ for	_______________________________
5. __________ for	_______________________________
6. __________ for	_______________________________
7. __________ for	_______________________________
8. __________ for	_______________________________
9. __________ for	_______________________________
[_]No backing        [_]Plastic backing	[_]Heat seal backing
SPECIAL INSTRUCTIONS:	ATTACH SKETCH OR SAMPLE:
[_]poor sample or rough sketch,      please improve.
[_]Make exactly like sample.
[_]With changes as noted.