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Choker Order Form

Instructions: Please print this form and mail with check or money order to:

Shelle's Hemp Haven

c/o Roshelle Day

244 SW Rimrock #4

Redmond, OR 97756


(Please make check or money order payable to Roshelle Day. For those sending checks, items will not be started until check clears the back.  $25 charge for bad checks.)


Use a separate form for each item. Up to 5 items may be ordered at any one time.




Please provide the following contact information:

First Name
Last Name
Street Address
Address (cont.)
Zip/Postal Code
Work Phone
Home Phone

Choose style:

Style A
Style B
Style C
Style D
Style E
Style F

Please choose size:

13 inch
14 inch
15 inch
16 inch
17 inch
18 inch

Please choose one or two colors of hemp:

Natural  Purple   Blue     Red    
Green    Yellow   Black    

Please choose bead color (one or two):

Metallic Blue                          Metallic Purple
                                         Clear lined with blue                
Clear lined with green
Clear lined with yellow                 Clear lined with red 
Clear lined with brown                 Green 
Japanese miracle beads (choose color)

Please choose type of charm:

Glass mushroom teardrop
Antique pewter serpent
Antique pewter frog
Antique pewter arrowhead
Antique pewter feather
Silver whale tail
Silver 4 leaf clover
Silver Chinese dragon
Pewter cannabis leaf
Zodiac (specify sign) 
Letter Beads (specify letter/s) 

Any additional comments or instructions:

*Shipping and handling fee $1.50 per item.

Total Price enclosed:    

**Print this form and send with check or money order to address above.


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Shelle's Hemp Haven
Copyright 1999 Sacred Dreams Web Design. All rights reserved.
Revised: July 18, 2001