Quality Challenge Coins Reorder 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***)

ANY CHANGES OTHER THAN METAL TYPE OR COLORS TO YOUR COIN'S DESIGN WILL REQUIRE A NEW DIE
TO BE MADE AND YOU CANNOT USE THIS FORM.
YOU MUST FILL OUT THE "NEW ORDER" FORM INSTEAD.

"*" DENOTES A REQUIRED FIELD
Incomplete or missing required fields may result in a delay of your order processing


Coin ID*

Quantity of Coins*   

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 contact*: (Same)

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

Payment Type : Choose One Credit Card Check Money Order Purchase Order AMOUNT $

CREDIT CARD TYPE: 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 (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*: