Eagle Gifts Galore
2707 S. DESERT FOREST AVE., ONTARIO, CA 91761   Voice: (909) 947-6634
Fax: (909) 947-6666     e-Mail:  egg@EagleGiftsGalore.net     http://www.Eagle Gifts Galore.net
EAGLE   SCOUT  POEM  PLAQUE  ORDER  FORM

If you are ordering an Eagle Scout Poem Plaque, use this form.
For Cub Scout Thank You Poem Plaques, please use the Cub Scout Thank You Poem Plaque Order Form.
For Boy Scout Thank You Poem Plaques, please use the Boy Scout Thank You Poem Plaque Order Form.
For Deluxe Poem Plaques, please use the Deluxe Poem Plaque Order Form.
For Photo Poem Plaques, please use the Photo Poem Plaque Order Form.

ORDER  FORM  INSTRUCTIONS
1.Enter your Background Paper choice.   (See Background Papers pages.)
2. Choose Poem.  (See Eagle Scout Poem Plaque page for poem wording.)
3.Choose Scout's starting Rank.      7. Total your order.
4.Select Plaque color.*      8. Fill in your contact information.
5. Fill in Date plaque is needed by.      9. Fill in payment information.
6. Enter your Troop # and Council Name.    10. Print Form.
7. Enter your Personal Message.      

*Some background papers look better in Walnut, some in Black Marble.
If you prefer, we can choose the best plaque color for your background paper choice.
Use your browser's "Print" feature to print this form, sign it, and Fax or mail it to the address above.

Please do NOT send Credit Card information via eMail.

POEM INFORMATION
Background Paper:  
Poem Choice:  
My Eagle Scout™ began as a:     Scout™
Select plaque color:  
Date plaque is needed by:   - -
Troop Number:  
Council Name:  

Personal Message
Eagle Scout's™ Name or Line 1
Sentiment or Line 2
Parent(s) Name(s) & Date or Line 3

* * * * * * * * * * * * * * * * * * * * * * * *


ORDER   SUMMARY
  Poem Plaque   @  $ 31.95   =  $   31.95
  Black Marble-Look Plaque   @  $   5.00   =  $     5.00
  Shiping & Handling   @  $ 16.50   =  $   16.50
  California Sales Tax*   @     8 %     =   $  
      Total   =  $  
* California Residents only

Billing Address
  Name          
 Address 1    
 Address 2    
 City              
 State                   Zip    
 E-Mail    
    Main Phone Number
   Home       Mobile  
    - -
  Second Phone Number
   Mobile       Work  
    - -

Shipping Address (if different)
We must have a phone number for the shipping address.
  Name             Phone     - -
  Address 1       City    
  Address 2       State     Zip    

PAYMENT   INFORMATION:
 Check Enclosed
  Please charge my Credit Card
  Pay with PayPal

CREDIT  CARD   INFORMATION:
Name on Credit Card:
First NameMiddle InitialLast Name
Please make sure that the Billing Address (above) is where the credit card statement is sent.
  Credit Card Type:      Visa     Mastercard     Discover  
CREDIT   CARD   NUMBER: EXPIRATION   DATE: SECURITY   CODE:
    (on back of card)
                  
 
 
Signature: ______________________________________________________________________________________

ES PP   Rev. Feb. 2016