Tell us your name and how to contact you:

First name: ______________________ Last name:__________________________

Title: _____________________ Organization: _____________________________

Address: ___________________________________________________________

City: ______________________ State: _______ Zip: _______________

Work Phone: ____________________ Home Phone: _______________________

FAX: __________________________ E-mail: ____________________________

Please describe yourself:

Date of birth: ___/___/___ Sex: Male___ Female ___

Height: ______ Weight____ Hair color: _________ Eye color: ___________

Significant Other’s name: ____________________________________________

Sig Other's Birth Date: ___/___/___ Anniversary date: ___/___/___

Children:

Name____________________________ Birth Date: ___/___/___

Name____________________________ Birth Date: ___/___/___

Name____________________________ Birth Date: ___/___/___

Name____________________________ Birth Date: ___/___/___

Special Occasions:

What? ________________________________ Date: ___/___/___

What? ________________________________ Date: ___/___/___

What? ________________________________ Date: ___/___/___

What? ________________________________ Date: ___/___/___

Preferences (select those items for which you want to receive sale notices):

[ ] Dresses   [ ] Accessories  [ ] Hosiery    [ ] Hats   [ ] Shoes/boots  [ ] Outerwear

[ ] Other (please describe) ____________________________________

Ordering information:

BILLING:

Credit card: ___ Visa ____ Master Card ___ Amex ___ Discover

Cardholder name: ___________________________________________