Just print this form and mail or FAX it to us.
We'll need a physical street address for UPS delivery of the print.
Name___________________________________________________________
Street Address____________________________________________________
City______________________________State_________Zip_______________
Telephone________________________E-mail__________________________
Credit Card: ___Master Card ___Visa
___Discover ___American Express
Card Number_____________________________Expiration Date__________
Signature________________________________________________________
Quantity Item Price Total
Limited
Edition Print:
_______ "The Dollar
of 1804" $125.00 $_______
_______ Framed Print $350.00 $_______
_______ 1804 Dollar Replica $29.95 $_______
_______ Replica - Double Set $49.95 $_______
Wisconsin residents add 5% sales tax $_______
Total for Order - U.S. Funds Only $_______
Your order will be shipped immediately upon receipt for payment by credit card, money order or certified check. If payment is made by personal check please allow time for check to clear before your order is shipped. Thank you very much!
414-233-6777
Make checks payable to and mail to: Reliance Numismatic Services, P.O. Box 177, Oshkosh, WI 54902-0177 For questions: E-mail us at: reliance@1804dollar.com