Mail or Fax this Order Form to:

ROYAL IMPRESSION BALLROOM DANCE SHOE COMPANY
3858 LATTIMER ST.
COLUMBUS (HILLIARD), OH  43026
FAX: 614-777-5680
PHONE (Local) 614-777-1080
PHONE (Toll Free): 1-877-546-1301

NAME: __________________________________________________

ADDRESS: _______________________________________________

CITY:                                                STATE:                     ZIP:

PHONE: Home (     )                                           Work: (     )

E-MAIL Address:

STUDIO AFFILIATION:

QTY STYLE COLOR HEEL HT. AMER. SIZE* ENG. SIZE* PRICE
             
             
             
             
 * Please don't forget to include width             SUBTOTAL  
OHIO RESIDENTS ADD 6.75%                SALES TAX  
SHIPPING AND HANDLING $10.00 per pair. Add $2 for each additional pair of shoes.  
Thank you for your order!                                  TOTAL  

Send check, money order, MasterCard, VISA, American Express along with this form payable to ROYAL IMPRESSION

VISA               MASTERCARD               AMERICAN EXPRESS          CHECK

Card No. __________________________________________ Exp. Date _________

Signature _____________________________________________