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This is an explanation of the purpose of the form ...

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

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 cannabais leaf
Zodiac (specify sign)
Letter Beads (specify letter/s)

Any additional comments or instructions:

Author information goes here.
Copyright 1999 [OrganizationName]. All rights reserved.
Revised: July 15, 2001