coinable.com - token order form
Print this form , complete all information, and fax to 623-266-7318 or print and mail to: coinable.com - 6635 W Happy Valley Road, Suite 104-469, Glendale, AZ 85310


 Quantity
Diamter/Inches
mm
Thickness/Gauge
Inches
mm
 
0.650
16.5
18
0.045
1.1
 
0.800
20.3
14
0.075
1.9
 
0.861
20.3
16
0.055
1.4
 
0.880
22.4
16
0.061
1.5
 
0.900
22.9
18
0.050
1.3
 
0.984
25.0
16
0.061
1.5
 
1.000
25.4
16
0.061
1.5
 
1.073
27.3
14
0.075
1.9
 
1.125
28.6
15
0.064
1.6

Metal:   Brass or Nickel plated brass


Customer ID________________________________ (assigned by coinable.com)      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)

Credit card#: b
Exp Date: b

Name on card: ___________________________________________________          Notes:___________________________________________________ 

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 http://www.coinable.com/tos.html, 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:_____________________
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