Order Form

G. E. Messinger Shoe Repair Order Form

QTY	SHOE DESCRIPTION	CORRECTION REQUIRED	PRICE

Please provide the following contact information:

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Home Phone
E-mail

	Billing
Card Type	Visa MasterCard AmexExp
Credit Card Number
Name as it appears in card
Expiration Date (month/year)

 

Signature of cardholder ___________________________________________________

Send to

     G.E. Messinger Shoe Repair

221 East Main St.

Medford, OR 97501

To print: right click on form and choose "Print"