Shipping Form – High Street Shoe Repair

SHIPPING INSTRUCTIONS

1. COMPLETE SHIPPING FORM BELOW

2. INCLUDE THIS FORM WITH YOUR ORDER

SORRY… NO INTERNATIONAL SHIPPING… WE DO SHIP APO/AFO

MAIL TO:

HIGH STREET SHOE REPAIR

233 HIGH ST. NE

SALEM, OR 97301

Customer Information

NAME

SHIPPING ADDRESS

CITY STATE ZIP CODE

PHONE

EMAIL

BILLING ADDRESS SAME DIFFERENT

IF DIFFERENT

Repair Order

#1

BRAND COLOR REPAIR COST

REPAIR

BLUNDSTONE SOLES Circle One (1705 / 1716 / 1752) DR. MARTEN SOLES Circle One (4014 / 1705) HAFLINGER / STEGMANN SOLES Circle One (1030 / 1328) SAS SOLES Circle One (1030 / 1328) LIFT – SIZE OF LIFT : COWBOY BOOT ZIPPERS

#1

BRAND COLOR REPAIR COST

REPAIR

BLUNDSTONE SOLES Circle One (1705 / 1716 / 1752) DR. MARTEN SOLES Circle One (4014 / 1705) HAFLINGER / STEGMANN SOLES Circle One (1030 / 1328) SAS SOLES Circle One (1030 / 1328) LIFT – SIZE OF LIFT : COWBOY BOOT ZIPPERS

Payment

PAYPAL – PLEASE SEND ME A PAYPAL INVOICE

CALL ME FOR MY CREDIT CARD INFORMATION

CARD TYPE VISA MC

CARD # EXP DATE MM/YY CVCC#