A. E. Kirkpatrick Jewelry Design                            Tel: 508-693-1632
PO Box 1926                                             
Vineyard Haven, MA 02568
U.S.A.

SOLD TO:                                 SHIP TO: (If not the same)

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Name                                     Name

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Address                                  Address

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City, State, Zip                         City, State, Zip

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Phone Number

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                                                      SUB TOTAL |          |
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                                For MA orders, add 5% sales tax |          |
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                                            Shipping & Handling |          |
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PAYMENT METHOD:                                           Total |          |
                                                                ------------
( ) Check Enclosed, Make check payable to "A. E. Kirkpatrick Jewelry Design".

( ) MasterCard, Visa or American Express

    Card Number: ______________________________  Expiration Date: ___________

    Signature: ______________________________________________________________

SHIPPING INSTRUCTIONS:_______________________________________________________

GIFT MESSAGE:________________________________________________________________