Order Form

Cremulet Order Form

Please Print and mail with cremains

(Click here for instructions on how to pack and mail cremains.)

Basic Design Options Please Tick Appropriate Boxes

Basic Color	Oval	Round	Heart	Arrow	Teardrop	With Hole	Like Sample Number...	Quantity	Price
RED
BLUE
GREEN
WHITE
BLACK
AMBER
TURQUOISE
Other (please specify in special instructions)

Special Instructions (Custom):______________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

NAME:__________________________________________________________________________

ADDRESS:_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Telephone No. & Email: ____________________________________________________________

Payment Options: U.S. $ CHECKS

Otherwise please supply your Credit Card Information Below or enclose a check or Money Order when you mail cremains with this order form.

Credit Card Number:_____________________________________________________

Expiration Date:_________________________________________________________

Credit Card ID Number:___________________________________________________

Name and Address of Cardholder
if different from shipping address___________________________________________

                                                      ____________________________________________

                                                      ____________________________________________

Mail With CremainsTo: Lewis Creek Glassworks, PO Box 1007, Neskowin, OR. 97149

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