OFF THE WALL
MAIL IN ORDER FORM

Send Check or Money Order to:

OFF THE Wall
RR 1 Box 1017
Bridgton, ME 04009-9755

Queries may also be sent to: barefoot@offthewallemporium.com
or phone: 207-647-3734
     fax: 207-647-5801

Please print out this form and fill in the appropriate information: (Please Print or Type Information)

Your Name____________________________________________________________
Street Address_______________________________________________________
City___________________________________________________
State_______________________________________
Zip______________________________
Phone__________________________
E-Mail Address__________________________________________

Shipping Address if Different From Above:
Name__________________________________________________________________
Street Address________________________________________________________
City_____________________________________________________
State___________________________________________
Zip_______________________________


ORDER:

PERSONALIZED CHILDREN'S STORIES:
Child's First Name____________________________________________
Nickname______________________________________________________
Boy/Girl_______________
Child's Age____________
Child's Birth Date_______________
Please list any pertinent information that will enable me to better
compose a story specifically about this child (unusual events,
likes/dislikes, personality etc)____________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

COST:           [  ] $100.00 for exclusive story
choose one     [  ]  $50.00 for author to retain rights to story

Allow 6 to 8 weeks for delivery upon receipt of payment.