SOUVENIR PRODUCT ORDER FORM - PRINT AND MAIL THIS ORDER FORM
Complete sign and mail order form with payment. Forms not signed will be discarded.
If field does not apply, leave blank. If you need additional fields, fill out custom field and print legibly…

Please use the fields below to include all information pertaining to your order. Information which is not relevant to your order will automatically be purged when your order is completed. Enclose any further info if needed.
SOUVENIR BIRTH:  NOW ONLY: US$99.00  Add Genuine Original Raised Seal $US35.00

FULL NAME AS ON NOVELTY BIRTH CERTIFICATE :                             FIRST                                                         MIDDLE                                                LAST

 


DATE OF BIRTH:                                                    SEX:                                               PLACE OF BIRTH:                                            HOSPITAL:

MONTH/DAY/ CENTURY AND YEAR                            M/F                                                 CITY/COUNTY/STATE/COUNTRY

 


FULL MAIDEN NAME OF MOTHER:

FIRST                                                         MIDDLE                                                LAST 

 


FULL NAME OF FATHER:

FIRST                                                         MIDDLE                                                LAST  
 

SOUVENIR DEATH:  NOW ONLY:  US$99.00 Add Genuine Original Raised Seal $US35.00

LEGAL NAME OF DECEASED:                             FIRST                                                         MIDDLE                                                LAST

 

DATE OF DEATH:                                           COUNTY/COUNTRY OF DEATH:                                                SEX   


DATE OF BIRTH OR AGE:          RACE:                         NAME OF SPOUSE:                                            NAME OF PARENTS:

                                                                                                            
 


SOUVENIR MARRIAGE OR DIVORCE:  NOW ONLY:  US$99.00 Add Genuine Original Raised Seal $US35.00

FULL NAME OF HUSBAND:                              FIRST                                                         MIDDLE                                                LAST

 

FULL MAIDEN NAME OF WIFE:                        FIRST                                                         MIDDLE                                                LAST

 

DATE OF MARRIAGE:                                               (OR) DATE OF DIVORCE:

 

IF MARRIAGE, COUNTY, STATE COUNTRY OF CERTIFICATE:                                  IF DIVORCE, COUNTY, STATE COUNTRY OF DIVORCE:

 

YOUR SIGNATURE:
 

     Add Shipping & Handling:  AUD $20.00  GBP 10.00     EURO €15.00       US$15.00 
Add Genuine Original Raised Seal AUD $45.00  GBP £35.00     EURO €35.00       US$35.00
 
RUSH ORDERS (CASH ONLY ) ADD  AUD $60.00  GBP £35.00  EURO €45.00    US$55.00
  

 
     Payment accepted in any of above currencies by: Cash ___Or Traveler Checks FOR FASTEST SERVICE 
 
or by International Postal Money Orders____   We DO NOT ACCEPT PERSONAL CHECKS OR US POST OFFICE LOCAL MONEY ORDERS. WE DO ACCEPT US post office  INTERNATIONAL MONEY ORDERS ONLY All checks will be held for 30 days and order shipped after clearance  

PLEASE SHIP MY SOUVENIR SOFTWARE DESIGN PRODUCTS TO MY ADDRESS BELOW!

Name:
 

Address:

City:

State/Province:

Zip:
 


Country:                         E-mail Address: _________________________________________   Phone Number: _______________________
 

Terms and Conditions:  I state I am the person whom I represent myself to be herein, and I affirm the information within this product application is complete and accurate. I represent, warrant and covenant that: I am at least eighteen years of age and have the full right and authority to enter into this Agreement. I do not reside in any country to which import of souvenir design products are prohibited or restricted. I will not use any of the souvenir software designs in any manner prohibited by any laws, restrictions or regulations. My use of the souvenir design prints does not violate any applicable law or regulation of the country, state, or other   governmental entity in which I reside and accept full responsibility for the accuracy of the information contained in this application as solely mine. I without reservation or restriction understand fully that you are not an an issuing authority of any governmental entity or agency that is authorized to issue official identification documents, means of official identification, or authentication features. Any original designs are sold for novelty, commemorative, celebratory, commemoratory, dedicatory, in memory, in remembrance, memorial, observing as a memento, or for a collection or exhibit, for decorative purposes, for a dramatic presentation, such as a theater, film, or television production or for for any other recreational, souvenir or amusement purpose, and not for any legal or official purpose, and any souvenir design is not an authentication feature issued by or under the authority of any government, state, political subdivision of a state, a foreign government, political subdivision of a foreign government, an international governmental or an international quasi-governmental organization. I expressly acknowledge you reserve the right to change, modify, update or discontinue any design for any reason and elect to replace any design with an alternate design as updates become available. I understand any souvenir product is not to be used for any official purpose, or to use, deal with or act upon it as if they were genuine, or to induce any person by the belief that it is genuine. I understand the use or mention of any product name, image or trademark on your web site is in no way intended to suggest that any novelty product is an officially issued design as all images are trademarks or registered trademarks of original designers, and are for reference only.

By signing this agreement, I attest, affirm, and
my signature below serves as evidence that I, the bearer/purchaser, agree to the aforementioned agreement in its entirety and do hereby certify and accept all the terms and conditions contained herein, and agree to be bound by its terms and conditions.
 
      
         __________________________________  X
_____________________     _____________________    

         Name                                                        Signature                   Date

NO FEDEX, UPS, USPS EXPRESS OR PRIVATE COURIER ACCEPTED. USE YOUR LOCAL POST OFFICE MAIL OR
Priority Mail or British Royal Express
FOR FASTEST SERVICE.                        
      

MAIL YOUR ORDER FORM AND PAYMENT TO ADDRESS BELOW:  If sending international money order or traveler checks  leave the 'Pay to:' / 'Payee:' / 'Pay to the order of:' field blank. Do not enter our mailing address in the payee field

                                                                                                                                           

GLOBAL MAIL REDIRECTION

34152 STN D
VANCOUVER, BC
CANADA V6J 4N2