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 |
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Options for Shield Cards
Badge #:________, $ 6.00
WaterMark?   , $18.00
Insurance? , $21.00
Order Confirmation? , $5.00
Veri-Fax w/order? , $10.00
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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:
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Delivery / Payment Section and Agreement Between Purchaser And Shield Card America.
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Please Print
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First Name
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Last Name
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| 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 |
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Buyer's Signature |
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Today's Date
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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 |
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Fax Number |
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BASKET
