Jewel Box Platinum

ALL FIELDS ARE REQUIRED.Plaque Order Form

ALL FIELDS ARE REQUIRED.

Product Information

Artist

album title

affiliation with the project

Include song titles if not affiliated with entire album

certification

plaque style

**NOTE: If a custom plaque has NOT been commissioned, you will be notified so you can choose a Standard Style plaque.

quantity

standard style

Please click here to view our "Standards Sheet" for descriptions of each style.

premium standard upgrade

Premium Standards include a gold or platinum lip around the frame and a suede mat.

Name as you'd like it to appear on the plaque

Attach a second sheet with additional names if ordering more than one plaque from the same artist and album.

supply the product CD

Please send one product CD for each plaque ordered to Jewel Box Platinum at the address listed below ATTN: Andrea Jensen. If you choose not to send a CD we will order one for you for $25 each.

Billing & Shipping Information

person

phone

card type

card number

exp. date

Name as it appears on the credit card

billing address

billing city

billing state

billing zip

shipping address

shipping city

shipping state

shipping zip

Your credit card will NOT be charged at this time.

We will send you an email confirmation within 2 business days of receipt. We will need to have your request approved by the respective record label before proceeding with your order. Due to the high volume of orders we receive daily, your patience is greatly appreciated during this process. If you do not receive a confirmation email within 2 business days of sending this fax, please email kate@Jewelboxplatinum.com