To order, please complete this order form.

This form does NOT automatically charge your credit card (Impact Card) for your purchase when this form is submitted. I will manually process your payment at the time that I actually begin working on your order.

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*FIRST and LAST Name:
*E-mail:
*AF Base Name:
*MAILING Address Line 1:
Address Line 2:
*City:	- *State: - *ZIP Code:
*Phone:	--- Extension:

*Date your order is needed by:

- mm / dd / yyyy

*Is this order a Rush order? Rush Order Information .

This is NOT a rush order - for 1 to 2 puzzles = 3-4 day lead time until shipped via 2 Day Priority mail. This is NOT a rush order - for 3 to 6 puzzles = 4-7 day lead time until shipped via 2 Day Priority mail. This is NOT a rush order - for 7 to 15 puzzles = 8-10 day lead time until shipped via 2 Day Priority mail. RUSH order - I need 1-2 puzzle(s) shipped within 1 business day - Add $40 per puzzle. (Includes 2 business day delivery in Continental USA, where service is available.) I only need a portion of my order RUSHED. - (Type your comments below) - Add $40 per "Rushed" puzzle. (Includes 2 business day delivery in Continental USA, where service is available.)

*Puzzle piece count desired:	36 to 42 piece puzzle - $175 per puzzle - (Most popular size ordered) 43 to 50 piece puzzle - $195 per puzzle
*Puzzle Price:	Select the quantity of puzzles you are ordering for your AF base. ONE (1) Puzzle = $175 / $195 TWO (2) Puzzles = $350 / $390 THREE (3) Puzzles = $525 / $585 FOUR (4) Puzzles = $700 / $780 FIVE (5) Puzzles = $875 / $975 SIX (6) Puzzles = $1,025 / $1,170 SEVEN (7) Puzzles = $1,200 / $1,365 -- No sales tax applies to HEARTLINK orders, and shipping is already included in the price.
*Magnetic?	No, Do Not Magnetize my Puzzle Yes, Magnetize the Puzzle(s). Price is $1.50 PER Puzzle Piece extra.
*Form of Payment:	PAYPAL Visa MasterCard American Express Check / Money Order - (Item is shipped after payment is received)
Credit Card Number:	ie: 1234 - 4567 - 9876 - 4321 a) Please use spaces or dashes between each grouping of numbers. b) Please double check the numbers once you have typed them. Thank you.
V - Code: Without this number, we can not process your order.	The 3 digit verification number located on the back of your Visa / Master Card or Discover card. With American Express there are 4 numbers, and they are located on the front of the credit card.
Card Expiration date:	- - Month / Year
The name exactly as stated on the credit card:

*Comments: Mark,