Belt Finishing Information

Please complete all of the information below. Then PRINT the form and mail it along with your belt to the following address:

NeedlepointShop.com

619 Straw Lake Drive

Brandon, FL 33510

Name

Work Phone

Home Phone

E-mail

Belt Description:

Choose one of the following options for the choice of:

leather color: buckle:

What is the belt waist size? Belt for:

Please provide the following shipping information:

SHIPPING

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Payment Method: Credit Card Number: Exp. date: Security Code

No charges will be applied to your credit card until the finished belt is shipped back to you.

Thanks for your order!