Order Form

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For mail orders, print out this page and record the items you wish to order. Kindly make your personal check or money order out to Jencius Coins. Orders ship at a flat-rate of only $4.50!

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Date: Name: Address:   Phone:   Email*:

_______________________ _______________________ _______________________ _______________________ _______________________ (in case there's any problem with your order) _______________________

Jencius Coins P.O. Box 280041 Brooklyn, NY 11228 Tel: 718-836-0674

Order Items

QUANT	DESCRIPTION	UNIT	TOTAL
	1)
	2)
	3)
	4)
	5)
	6)
	7)
	8)
	9)
	10)
	11)
	12)
N.Y. Tax
Postage			$4.50
TOTAL

Check/Money Order Enclosed # __________ TOTAL AMOUNT __________

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* 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.

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