Icons Order Form
 

Description of Item	Price	Quantity
Faberge Icon - Jesus Christ	$10,000
Shipping Via UPS Insured

Name:
E-mail Address:
Address:
City:		State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming	Apt. #:
Zip:		Telephone #:

Payment Method:	American Express Diner's Club Discover Master Card Visa Money Order	Name on Card:
Card Number:		Exp. Month:	January February March April May June July August September October November December	Exp. Year:	05 06 07 08 09

RHenn@
ImportSpecialist.com

513.779.2288

6924 Dimmick Road
West Chester, OH 45069-4000

Safari Club International Convention

Dallas Safari Club

Colorado Fossil Expo

Detroit Gem, Mineral & Fossil