Name:
Address:
City:
State:		ZIP:
Phone:		E-mail:

Item Name or Number	Metal/Stone Request	Price Each	Quantity	Total
Bracelet purchase: Please indicate SIZE:
"Name Bracelets": Indicate the name(s) to be used:
Date of Order:			Total Due $

Please make checks or money orders payable to:  Nina Nomi Jewelry
Charge cards accepted:  Visa, MasterCard, AmEx, or Disc
Credit Card #		Exp. Date:
Signature

• [  ] Check here if you wish item to be shipped to address other than indicated above  ... please write person's name and their shipping address on back of this form.
• We must include 6% sales tax for Florida residents
• THANK YOU FOR YOUR ORDER!