AWESOMEGEMS.COM - MAIL or FAX ORDER FORM ------------------------------------------------------------------- Bill and Ship to: (no P.O.Boxes) Name_______________________________________________________________ Address____________________________________________________________ City_____________________________State_________________Zip_________ Country____________________________________________________________ Home Phone______________________ Business Phone___________________ e-mail address:____________________________________________________ -------------------------------------------------------------------- GEMSTONES: 1-Item #:________ Desc:_________________________________ Weight:________ Shape:____________ Per Carat$_______ $__________ 2-Item #:________ Desc:_________________________________ Weight:________ Shape:____________ Per Carat$_______ $__________ JEWELRY ITEMS: 3-Item #:________ Desc:_________________________________ (circle one) Platinum-18K-14K Color_______ Size:____ $__________ 4-Item #:________ Desc:_________________________________ (circle one) Platinum-18K-14K Color_______ Size:____ $__________ MISC ITEMS: 5- aa58-827 Selvyt Gem Cloth 5x5 Qty:____ @ 4.95ea..$__________ 6- aa58-829 Selvyt Gem Cloth 14x14 Qty:____ @ 14.00ea..$__________ 7- aa52-845 Rouge Cloth 10x10 Qty:____ @ 7.95ea..$__________ 8- aa68-011 UltraSonic Cleaner Qty:____ @ 99.00ea..$__________ 9 -aa68-070 Power99 Solution Qty:____ @ 10.00ea..$__________ 10-aa68-040 Ionic Cleaner Qty:____ @ 99.00ea..$__________ 11-aa68-044 Ionic Solution Qty:____ @ 10.00ea..$__________ 12-aa68-045 bi-pass Transformer Qty:____ @ 16.00ea..$__________ 13-aa51-012 Jewelers 10x Loupe Qty:____ @ 10.00ea..$__________ My Subtotal is ....................................... $___________ (if delivered in Calif.) 8.75% sales tax..$___________ Shipping Costs..$___________ My Total is.. .........................................$___________ -------------------------------------------------------------------- Chart for Shipping (within U.S.) if total is over $0 and under $9..............add $2.50 - USPS if total is over $10 and under $20............add $5.50 - USPS if total is over $21 and under $50............add $10.00 - UPSG if total is over $51 and under $100...........add $15.00 - UPSG if total is over $51 and under $100...........add $18.00 - UPS2d if total is over $101 and under $500..........add $20.00 - UPSG if total is over $101 and under $500..........add $28.00 - UPS2d if total is over $101 and under $500..........add $35.00 - UPS if total is over $500 and under $2,000........add $50.00 - UPS if total is over $2,000 .......................... Please Call USPS=U.S.Postal Service, UPSG=UPS Ground UPS2d=UPS 2 day, UPS=UPS Overnight ---------------------------------------------------------------------- Payment can be credit card, check, money order, or bank wire Visa/M/C/Disc/Amex _______________________________Exp. Date_________ on back of card: Bank Phone ________________________CID# __________ Signature____________________________________________________________ Yes, I hereby authorize this charge --------------------------------------------------------------------- Mail the completed form with your payment to: Rodrigue & Sons Co. 116 E. College Ave. Suite 170 Lompoc, CA 93436-5335 USA. or FAX completed form to 805-737-9846 (we accept checks by FAX too!) Questions? Call: 1-800-549-0571 or Int'l calls 805-735-7103