Punctuation, Inc.

Sample Request Order Form

218 Richardson Street
Brooklyn NY 11222

Phone: (718) 383-8855 Fax: (718) 383-8873 www.champ-sys.com

Team Name _______________________________________ Contact Person ____________________________________

Daytime Phone (_____)_________________ Fax (_____)_________________ Email ______________________________

Ship to: Bill to:

________________________________________ ___________________________________________

________________________________________ ___________________________________________

________________________________________ ___________________________________________

Check one: ___ Residential Address ___ Business Address

Internal Use Only

Please list the three samples you would like to receive: Rep Name: ________________________

__________________________________________________________ Invoice #: ________________

__________________________________________________________ Date: _____________________
__________________________________________________________

Note: Do not list sizes. These samples are for quality review only. Sizing samples will be sent upon receipt of your
artwork and deposit.

Bill to (check one): ______VISA ______ MasterCard

Name on Card ________________________________________

Card # ___________________________________ Exp. Date____________ 3 Digit Code On Back of Card _____________

Billing Address ______________________________________________________________________________________

Cardholders Signature_____________________________________________

Sample Prices: Jerseys/Vests/Shorts/Bibs: $50 / Skinsuits/Jackets $80 / Accessories $20

Our Policy Regarding Samples

Samples are sent for review purposes only and are not to be used. It is the customers
responsibility to ensure that all samples are returned in good condition. All damaged
samples and/or samples not returned within 7 days of receipt will be charged to your
credit card. We have a limited supply of samples so please return the items when you
have finished your review.

** Please return this form with your samples **