- Order Form -

Please allow 4 - 8 weeks for delivery.

Name

Title

Organization

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

FAX

E-mail

URL

3 Easy Steps

Step 1

Select Style of Memory Mirror:


	1A	3A	6A
	1B	3B	7A
	1C	3C	7B
	2A	4A	7C
	2B	4B	7D
	2C	4C

Select Size of Reliquary Chest:

	Small
	Medium
	Large

Step 2

Select Finishing Code :

	CODE	DESCRIPTION
	AV	Antique Verdigris (aged copper look)
	TS	Tarnished Silver (unpolished silver look)
	AB	Antique Black (aged black finish)
	FS	Fossil Stone (tan rock look)
	AP	Antique Pewter (old pewter look)
	PC	Personal Color (any color - Old World Art look)
	GM	Green Malachite (tones of green mineral rock)
	FM	Faux Marble (marble look - your color choice)
	FT	Faux Torte shell (tones of yellow/brown/black)
	CC	Celadon Crackle (similar to celadon ceramics)
	AW	Antique White (aged white)
	F B	Faux Bronze (aged bronze look)
	GC	Gold Crackle ( fine cracks in gold)
	AG	Antique Gold (aged gold look)
	MG	Mottled Gold (various shades of gold)
	BG	Burgundy/Gold (burgundy with gold trim)
	F G	Faux Gold/Bronze (gold/bronze mix aged)
	LL	Lapis Lazuli (rich blues/gold/blacks)
	WT	Wood Tones (any wood color with gold trim)
	WP	Worn Paint (base coat shows through)
	S G	Silver/Gold (silver/gold mix)
	OB	Old Brass (aged brass)

Step 3

Custom Features

I would like to personalize my choice with:

Step 4

Custom personalization items (please send your custom personalized items to Yartys.com, 1727 England Ave,
Courtenay, BC, Canada, V9N 2P5)

	Personal Items have been sent
	No Personal Items are required
	Personal Items (waiting for further info)

Shipping

Your order will be safely packaged, insured and sent by the most economical means available unless otherwise instructed.

Special Instructions

Thank you for ordering your truly unique and beautiful heirloom quality
Memory Mirror and/or Reliquary Chest