BASS RIVER SHOE REPAIR ORDER FORM

Print this form and put it in the box with your shoes. Use bubble wrap, tissue paper or newspaper to cushion your shoes and prevent movement in the box during shipping.

CUSTOMER INFORMATION

Name:  ______________________________________________________

Address: ____________________________________________________

______________________________________________________________
    
Daytime Phone: ______________________________________________
    
E-mail: ______________________________________________________
    

All prices given over e-mail or phone are subject to change depending on condition of shoes. We will confirm the price with you prior to charging your card.

BILLING INFORMATION

VISA  ____   MasterCard_____     Discover_____

Credit Card #__________________________________ Exp. Date______  CSC No. ____

Billing Address_______________________________________________

______________________________________________________________


Card holder name ________________________________________


Signature ___________________________

SHIPPING INFORMATION

 Ship the items needing repair to:
Bass River Shoe Repair
146 Old Main Street
S. Yarmouth, MA  02664

THANK YOU FOR YOUR BUSINESS!  We enjoy serving you!