Shield Card America Order Form
Questions? Call: (801) 465-4313     Fax Order To: (801) 465-4188
Complete All Sections and Send with your check for the most economical purchase.
There is a $20 dollar fee for returned checks.

Date:_____________ Style #: ____________ Pin#:_____________

Item Ordered:
Shield Cards Acrylic Paperweight Ceramic Paperweight
Shield Notes Shield Pen Calendar
Business Card Case SAC Cuzzi
Wall Plaque Range Tag(s) Mug
Award Coaster

Options for Shield Cards
Badge #:________, $ 6.00
WaterMark? , $18.00
Insurance? , $21.00
Order Confirmation? , $5.00
Veri-Fax w/order? , $10.00
Organization Name (Abbreviations O.K. Full Name Will Print)
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Your Name As You Want It To Appear On Shield Card
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Title/Rank
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Division/Special Task Force
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E-Mail Address
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Street Address
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City, State, Zip Code + 4
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(Optional Data Line)
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Area Code & Telephone Number
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Area Code & Fax Number (If Applicable)
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Pager or Mobile Phone (Circle One)
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Each Sample Has a (Red) 8 Digit Identification Number. Indicate Your Choice Here:
Delivery / Payment Section and Agreement Between Purchaser And Shield Card America.
Please Print
First Name
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Last Name
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Street Address
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Apartment No
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City
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State
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Method Of Payment


Check Number ______________
Money Order
Credit Card

Credit Card Type

Master Card
Visa
American Express		 Discover
Diners' Club
Credit Card Number
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Expiration Date

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Total Amount In U.S. Dollars for my purchase

$________________
TOTAL

$______________
The Issuer of my credit card identified above is authorized to pay Shield Card America the amount shown as TOTAL (above) upon proper presentation thereof. I promise to pay such TOTAL amount (together with any other charges due thereon) subject to and in accordance with the agreement governing the use of such card
X __________________________________________

Buyer's Signature
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Today's Date
Merchant Name & Address: Shield Card America P.O. Box 58 Payson, Utah 84651-0058
Phone: (801) 465-4313
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Name Of Individual Placing Order
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Telephone Number		 ______________________

Fax Number