PatchPlaque Patch to Plaque Order Form (Please print this page and fill out the form) ORDER# 2008-14677 INSTRUCTIONS Please print the following form, fill it out, and then send it to us. Be sure to include your patch and payment. Because every order is a Custom Order, we can not ship COD. Colors of the reproduced patch as a finished plaque may vary slightly. PATCH INFORMATION Enter the description of the patch that you would like made into a plaque: (Example: New York Fire Department)       AWARD TAB OPTION Would you like to add a black award tab to your plaque? Black  ($12.95) Color coordinated ($17.95) Large Format Plaques - Black or Color ($34.95) Up to 4 lines of text (28 characters/line max. including punctuation and spaces) Line 1: Line 2: Line 3: Line 4: ORDER PRICING Total of ________ plaque(s) ordered at $_______ each = $ _____________ + Total of ________ award tab(s) ordered at $_______ each = $ _____________ + Total of ________ plaque(s) shipped at $________ each = $ _____________ + Florida residents add 6.5% sales tax   = $ _____________ + (shipping charges are noted on our pricelist) Total   = $ _____________ SHIPPING INFORMATION (additional charges apply for coutside continental USA shipments) Name: Street Address: Suite/Apt.: City: State:          Zip: Phone (Days): (Eves): Email address: BILLING INFORMATION (leave blank if address is the same as shipping address) Name: Address: Suite/Apt.: City: State:          Zip: Phone (Days): (Eves): Method of payment:    Check or Money Order               Account #: Expiration: Signature: Security Code: NOTICE The overall quality of your finished plaque is directly related to the condition of the original that you send us. Try to give us the cleanest patch possible. Do not staple, paper clip, or fold patch. Simply place the patch within a clean piece of folded white paper and send it to us, along with the completed order form, in any envelope that fits. Your patch and your custom plaque will be shipped to you within three weeks. If your patch is valuable, we recommend that you insure it when you send it to us. In the event that PatchPlaques.com loses or accidentally destroys your patch, we will replace it when possible or refund the replacement cost, not to exceed twenty five dollars ($25.00), as exclusive remedy. Please send your patch, this completed order form, and your payment to: PatchPlaques.com P.O. Box 250180 Daytona Beach, FL 32125 If you have any questions about your order, contact us at info@patchplaques.com or by phone, toll free, (888) 671-2130 or by fax at (386) 676-9117. We sincerely appreciate your business! © 2002 PatchPlaques.com

Pricing for any mix of images* Qty PatchPlaques PhotoPlaques BadgePlaques S&H 1-6 $39.95 each $49.95 each $69.95 each $6.95 each 7-24 $36.50 each $46.50 each $66.50 each $4.00 each 25+ $34.95 each $44.95 each $64.95 each $3.00 each Pricing for the same image Qty PatchPlaques PhotoPlaques BadgePlaques S&H 48+ $32.50 each $42.50 each $62.50 each $2.00 each Award Tab Option A personalized award tab can be added to any of the above plaques for only $12.95 additional in black or $17.95 additional for a color coordinated award tab. Both options allow 4 lines of text, 28 characters per line. Award tab area is approximately 1.5" x 3". Large Format Plaques Size Price S&H Up to 15" wide but not more than 22" high $99.50 $10.00 Up to 20" wide but not more than 30" high $159.95 $15.00 Up to 24" wide but not more than 36" high $189.95 $20.00 Up to 30" wide but not more than 40" high $249.95 $30.00 Large Format Award Tab Option Award Tab Option For ALL 4 Large Format Plaque SIZES, Your Choice of Blank Black or COLOR, or Personalized Black or COLOR Size of area is relative to plaque size, no limit to amount of text. Only $34.95 additional!   *Info * Any mix of images means you can order several plaques at the same time and they can all have different images. PatchPlaques - Larger than life color reproduction of your Patch PhotoPlaques - Timeless Family treasures preserved Forever BadgePlaques - Larger than life color reproduction of your Shield