Send to:Carol Shireena Sakai, P. O. Box 3324, Falls Church, VA 22043. Questions? Email css82@juno.com or call 1-888-257-2962.  FAX=(703)-356-2183 (call- to make sure fax modem is on) 

Name_________________________________________________________ Address_______________________________Apt.No.________________ City__________________________________State______Zip__________ 

For Credit Card Orders, please include both Billing and Shipping Address
Phone (___)______________________________E-Mail_____________________________

Couple's post wedding address:___________________________________________

Check list information - please specify in detail if important for sculpture (use additional pages if necessary):
Bride name
height
eye color
hair color
hair style, up or down?
veil, length
gloves
jewlery -specify if important
shoes, describe
Groom name
height
eye color
hair color
tuxedo style, color
tie,vest,pocket sq
jewlery
boutinniere, color
shoes, describe
VA RESIDENTS ADD 5.0% Sales Tax 
___Enclosed is my check or money order for 1/2 the price of the sculpture. (Please send checks by certified mail).
The total price for the sculpture is _______ with _______ payable upon completion. 
The requested completion date is _____________. Shipping and handling costs will be paid by customer.

Charge to:___Visa___MasterCard

____ ____ ____ ____ - ____ ____ ____ ____ - ____ ____ ____ ____ - ____ ____ ____ ____ 
Exp Date:___/___  3 digit code on the back of the credit card ___ ___ ___

Please sign release form:

I give Carol S. Sakai permission to display, reproduce photographic images of me or sculptures of me for the purposes of art, advertising or trade.

Signature(bride)___________________________Date__________

Signature(groom)__________________________Date__________