coinable.com - order form
Print this form , complete all information, and fax to 623-266-7318 or print and mail to: coinable.com - 6635 W Happy Valley Road, Suite 104-469, Glendale, AZ 85310

Quantity of coins: ______________ (You can always increase your order, but only before your final approval of the artwork or sample coin.)

Coin size:   1.56"           1.75"           2"           2.25"           2.5"           2.75"           3"           3.25 "           3.5"            4"           Special shape (2")

Metal finish:   Antique Bronze          Antique Copper          Shiny Silver          Antique Silver          Matte Silver          Shiny Gold
 
                              Antique Gold          Matte Gold          Nickel          Matte Nickel          Black Nickel          Rhodium          Imitation Rhodium

Color(s):   None          1 side (5 or less on one side)          2 sides (5 or less colors per side)

Extra colors: How many? ________ (If silk screening is desired, please circle silk screening and place the number of colors as extra colors.)

Features: (Please circle or check those that apply for your coin.)
   EPOXY: ____ 1 side ____ 2 sides          SANDBLASTING: ____ 1 side ____ 2 sides          CUTOUTS: ____ (How many?)
 
   NUMBERING (stamped on a raised block)         LASER ENGRAVING - # of characters ____ (EDGE of coin, or FACE)              
 
   TWO TONE PLATING (for Shiny and Matte metal coins)          SPOT PLATING (for Antique metal coins)
 
   PHOTOGRAPHIC PRINTING: ____ 1 side ____ 2 sides          SILK SCREENING (for small non-paintable areas)
   
   Special paint:   PEARLESCENT            GLOW          HEAT CHANGING          TRANSPARENT # ____

    Edging:   REEDED EDGE          DIAMOND CUT EDGE: ____ FLAT ____ TWIST____ WEAVE          ROPE EDGE          KEY CHAINS

    Presentation:   # ____ PLASTIC CAPSULES (25 minimum purchase)          # ____ VELVETEEN BOX (Blue, Red or Black)


Customer ID________________________________ (assigned by coinable.com)      We accept :AMEX / VISA/ Master Card/ IMPAC

____ New Order   ____ Reorder           Amount Being Charged:$______________       Promo Code:_______________________________

ORDER TYPE: ____ REGULAR w/sample coin          ____ REGULAR, NO sample coin           ____ RUSH ORDER (additional fees apply)

Routing#_______________________________________ Account#_____________________________________ Acct Type_____________________________________

Bank Name: ___________________________________________________

Name on account: ___________________________________________________

Billing address: __________________________________________________

                                      __________________________________________________

                                      __________________________________________________

Shipping Address: (POC) __________________________________________________          BLIND ____

                                                                (Same?___) __________________________________________________

                                                                 __________________________________________________

Telephone Number: (day)_____________________________ ( ____ evening or ____ cell)_____________________________

e-mail address for receipt of payment:, only one email per line  

 ____________________________________________________________________________

e-mail address for artwork approval: (Same?____)

____________________________________________________________________________

By signing this order form, you certify that you are authorized to sign the debit or credit card listed above, that you have read and agree with the terms of service as listed on our web page at http://www.coinable.net/tos.html, that you agree to have the above credit or debit card charged for the merchandise placed by this order, and if applicable, all artwork, cancellation and die fees as explained more fully in the terms of service.


Signature:_________________________________ Printed name:_________________________________ Date:___________________
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