- order form
Print this form , complete all information, and fax to 623-266-7318 or print and mail to: - PO Box 214 Swink, CO 81077

Quantity of coins: ______________ (You can always increase your order, but only before your final approval of the artwork or sample coin.)

Coin size:   1.56"           1.75"           2"           2.25"           2.5"           2.75"           3"           3.25 "           3.5"            4"           Special shape

Metal finish:   Shiny Copper           Antique Copper          Shiny Silver          Antique Silver          Matte Silver

Shiny Gold          Antique Gold          Matte Gold          Nickel          Matte Nickel          Black Nickel          Dyed Black

Imitation Rhodium
          Rhodium          Chromium          Shiny Brass          Antique Brass          Shiny Bronze          Antique Bronze

3D (relief cut into the coin):   None     1 side     2 sides      Paint/Enamel (8 or less per side):   None     1 side     2 sides     ____ SOFT ____ HARD

Extra colors: How many? ________ (If silk screening is desired, please circle silk screening and place the number of colors as extra colors.)

Features: (Please circle or check those that apply for your coin.

   EPOXY: ____ 1 side ____ 2 sides          SANDBLASTING: ____ 1 side ____ 2 sides          CUTOUTS: ____ (How many?)

   NUMBERING          LASER ENGRAVING - # of characters
____ (EDGE of coin, or FACE)

   TWO TONE PLATING (for Shiny and Matte metal coins)          SPOT PLATING (for Antique metal coins)

    PHOTOGRAPHIC PRINTING: ____ 1 side ____ 2 sides          SILK SCREENING (for small non-paintable areas)

   Special paint:   PEARLESCENT            GLOW          HEAT CHANGING          TRANSPARENT #
____ # ____ # ____ # ____ # ____

    Edging:   REEDED EDGE     DIAMOND CUT EDGE:    FLAT ____   PETAL CUT ____   TWIST ____   WEAVE ____

      ROPE EDGE - 2D or 3D         KEY CHAINS

    Presentation:   # ____ PLASTIC CAPSULES (25 minimum purchase)          # ____ VELVETEEN BOX (Blue, Red or Black)          ____ RF Sleeve (100 min)  

Customer ID________________________________ (assigned by      We accept :AMEX / VISA/ Master Card/ IMPAC

____ New Order   ____ Reorder           Amount Being Charged:$______________       Promo Code:_______________________________

ORDER TYPE: ____ REGULAR w/sample coin          ____ REGULAR, NO sample coin           ____ RUSH ORDER (additional fees apply)

Routing#_______________________________________ Account#_____________________________________ Acct Type_____________________________________

Bank Name: ___________________________________________________

Name on account: ___________________________________________________

Billing address: __________________________________________________



Shipping Address: (POC) __________________________________________________          BLIND ____

                                                                (Same?___) __________________________________________________


Telephone Number: (day)_____________________________ ( ____ evening or ____ cell)_____________________________

e-mail address for receipt of payment:, only one email per line  


e-mail address for artwork approval: (Same?____)


By signing this order form, you certify that you are authorized to sign the debit or credit card listed above, that you have read and agree with the terms of service as
listed on our web page at, that you agree to have the above credit or debit card charged for the merchandise placed by this order,
and if applicable, all artwork, cancellation and die fees as explained more fully in the terms of service.

Signature:_________________________________ Printed name:_________________________________ Date:___________________