FINE CUSTOM LAMINATED WALL PLAQUES THERMO PLAQUE COMPANY INC. 14928 Calvert St., Van Nuys, CA 91411 CUSTOMER SERVICE (800) 245-7525 FAX (818) 988-8144  PHONE (818) 988-1080 NOTHING HAPPENS until this order form is printed out, filled out, and mailed to us with your diploma (or photo, etc.) 1. SOLD TO Name Street City, State, Zip Phone (            ) Fax (             ) E-mail address (optional) ____________________________ Will not be shared or sold. Used only for occasional promotions. 2. SHIP TO Name Street City, State, Zip Phone (            ) Fax (             ) 3. METHOD OF PAYMENT   I have enclosed a Check or Money Order Made payable to Thermo Plaque Co., Inc.    Check #_____________ Credit Card Account# Please Circle      Expiration Date  We will contact you by phone for security code. Print name as it appears on card _____________________________________ Signature (Required)___________________________ 4. DOCUMENT DESCRIPTION     (Photo?     Diploma?     News Article?    Name or Title?) IMPORTANT IF YOU HAVE ANY QUESTIONS, DO NOT HESITATE TO CALL CUSTOMER SERVICE (800) 245-PLAK (800) 245-7525 5. DOCUMENT SIZE measure and calculate below: COST Length______ inches X Width_______ inches= square inches Refer to price chart for cost, and enter it to the right. 5. 6. MULTIPLE ITEM LAYOUTS 6. If two or more items on one Plaque, $6.00 each piece. 7. BACKGROUND COLOR (Circle One) 7. 1. Red     2. Blue    3. Black     4. White     5. Green     6. Orange     7.Yellow   8. Black Walnut      10. Elm Burl     11.Teak Wood 12. Cherry Wood   13. Red Mahogany   14. California Redwood    15. Oak N.C. 8. DOCUMENT TRIM & EDGE PAINT Standards for both are Gold. Any Substitution is $6.00 each: 8. Document Trim (Circle or write in choice):     1. Gold Trim       2. Other_______________________ Please use two trim colors around my document: ___________________      ____________________                               First color (touching document)       Second Color     Edge Paint (Circle or write in color):   4. Gold Edge Paint (no charge)     5. Other__________ 9. THERMO PLAQUE SURFACE FINISH (Circle One) 9. 1. High Gloss (no charge)        2. Non-reflective Satin ($6.00)         Subtotal     ________ Sales Tax (California Residents Add 8.75%)      ________ 10. SHIPPING AND HANDLING: Calif. $9.95 For the 1st Plaque, $6.00 each add'l plaque 10. 11. Check this box for additional shipping insurance .99¢ 11. If anywhere in the Continental U.S. - Alaska, Hawaii & foreign countries by quote: Call customer Service. If ordering more than one Plaque, print another order form, but pay only $6.00 postage for the add’l plaque. Total    ________