JEREMY ATKINSON - MASTER CLOG MAKER
PRINTABLE ORDER FORM

Your Name .................................................................................................................
Address .................................................................................................................
.................................................................................................................
Post Code/Zip ............................................ Country ............................................
Telephone ............................................ Fax ............................................
Email .........................................................................................................................

I would like to order ORDER VALUE £
1. Type of Clog ................................................... ...................................
2. with the following extras
.............................................................................
.............................................................................
............................................................................. ...................................
Value of Order Excluding Postage ...................................
Postage ...................................
TOTAL ORDER VALUE ...................................

I enclose £30 (or equivalent in US$) as my deposit (please tick) [ ]

I take Pay Pal. E me for details.


Don't forget to enclose your foot/sole outline.

Orders should be sent to:

Jeremy Atkinson, 44 Duke Street, Kington,
Herefordshire HR5 3DR. U.K.