Quality Challenge Coins (wemakecoins.com) 24HR Order Form
Please fill out this web form. Print it out and fax it back to us at 717-230-8962
(***Order form CANNOT be submitted online***)
New Order     (Please select Order Type for a New Order)   ORDER TYPE --- Choose One Artwork Only (for approval) Artwork / Sample Coin Rush Order (new orders only)

Reorder      Customer ID

Quantity of Coins   Metal Type:    Choose One Bronze Gold Shiny Silver Antique Silver Black Nickel Copper Combination

Color:     Choose One No Color 1 side color (5 colors or less) 2 sides color (5 colors or less) Coin size:      Choose 1.56" 1.75" 2" 2.25" 2.5" 2.75" 3" Custom      

Extra Features: Please click on the boxes below for the extra features that you would like to select for your coin design.

Epoxy              Sandblasting       Silkscreening   Numbering                  Laser Engraving     Cut Outs 
Gold Plating   Silver Plating      Glow Paint        Transparent Paint     Special Shape Coin 
Reed edge      Twist Diamond Cut Edge                    Flat Diamond Cut Edge

Notes: Please only type as far as the text area shows because the remainder of the text will not print.


Customer Information--------------------------------------------------------------------------------------

Phone Number:  Day   Evening   Cell

Billing Address:                                                                   Shipping Address (Same:  
   
   
   

Email Address for receipt of payment

Email Address for artwork approval: (Same

Credit Card Information-------------------------------------------------------------------------------------

CREDIT CARD TYPE: Choose One VISA MASTER CARD AMERICAN EXPRESS AMOUNT BEING CHARGED $

Name as it appears on the Credit Card_
Credit card number: --- Expiration Date:

C V V 2 Code: Last 3 digits on the BACK of the card (Visa / Master Card) Last 4 digits on FRONT of (Amer Exp) card

By placing this order, you certify that you are authorized to sign on behalf of the credit card holder,
and you agree to our terms of service as listed on our website at http://www.wemakecoins.com/terms.html


Signature:_____________________________________________________ Date:___________________________________

Printed Name: