Order Form

For mail orders, print out this page and record the items you wish to order. We accept payments by VISA, MasterCard, AmericanExpress as well as personal check or money order. Orders are shipped via First Class or Priority Mail. Shipping rates. Please contact us for international shipping rates.

Date__________________

NAME________________________________

ADDRESS_____________________________

Jencius Coins

P.O. Box 280041

Brooklyn, NY 11228

Tel: 718-836-0674

Fax: 718-836-8554

________________________________________________________________

Tel. # (in case there’s any problems with your order) ________________________

E-mail*______________________________________________

ORDER FORM

QUANT

DESCRIPTION

UNIT

TOTAL

 

1)

 

 

 

2)

 

 

 

3)

 

 

 

4)

 

 

 

5)

 

 

 

6)

 

 

 

7)

 

 

 

8)

 

 

 

9)

 

 

 

10)

 

 

 

11)

 

 

 

12)

 

 

N.Y. Tax

 

 

Postage

 

 

TOTAL

 

 

Check/Money Order Enclosed #____________

TOTAL AMOUNT__________

VISA/MasterCard/AmEx# __/__/__/__/__/__/__/__/__/__/__/__/__/__/__/__

Expiration Date ___________

Signature ___________________________

* E-mail address is used to notify the customer of shipping date and is not required. The e-mail addresses of our customers are not disseminated or otherwise used for marketing purposes without our customers’ active permission.

To order, telephone Peter Jencius at 718-836-0674 or e-mail