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ORDER FORM
 
To order, please print out this form and send to:

Michelle Kaptur
23545 Rickard Road
Bend, Oregon  97702


 CHECK LIST

·        Order form is filled out and enclosed.
 

·      Cremation ashes are included in a zip lock bag.  (1 tsp.)
 

·      If paying by check, confirm check is made out to Michelle Kaptur and shipping fee is enclosed.
 

·      The most secure way to send ashes and check is via UPS with a tracking number.


Print and use one form for each companion. 
You can also mix different ashes together in one SoulBurst.

Shape Color Price
     
     
     
     
     
     
  Sub-Total:  
Discount                     
Subtract 10% if you ordered 3 or more SoulBursts with the same ashes

Sub-Total X .10 =

-
  Sub-Total:  
Shipping Cost
US Shipping is 6% of total order price

Sub-Total X .06 =
 

+
  TOTAL DUE:  

Name ___________________________________________
Shipping Address _________________________________

City ___________________State ______  Zip ___________

Phone (_____) _______ - ____________________________

Email Address ____________________________________

Person or Companions Name _______________________

Method of Payment  _______________________________

Who referred you to Soulbursts?  ____________________