Quality Challenge Coins New Order Form
Please fill out this web form in its entirety. Print it out and fax it back to us at 717-230-8962
"*" DENOTES A REQUIRED FIELD
Incomplete or missing required fields may result in a delay of your order processing.
ORDER TYPE* --- Choose One Standard Order (Artwork Only for approval) Artwork / Sample Coin (adds 30 days to order timeline) Rush Order (includes $100 RUSH fee plus Shipping charges)

Quantity of Coins*   Metal Type*:    Choose One Bronze Gold Shiny Silver Antique Silver Black Nickel 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" Special Shape      

Edging*:   Choose One Standard Rope Twist Diamond Cut Flat Diamond Cut Reeded

Extras: Please click on the boxes below for the extra features that you would like to select for your coin design.
Any features listed on your pricing estimate that are not seen below should be added in the Notes section.

Epoxy              Sandblasting    Numbering   Laser Engraving     Cut Outs    Photographic Printing
Gold Plating    Silver Plating  Two-Tone Gold Plating    Two-Tone Silver Plating    

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)

Payment Information-------------------------------------------------------------------------------------

Payment Type Choose One Credit Card Check Money Order Purchase Order AMOUNT $
 
CREDIT CARD TYPE: Choose One VISA MASTER CARD AMERICAN EXPRESS

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 (AMEX) 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*: