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UNIQPIX  ORDER  FORM
PRODUCT:             ____ PROUD AMERICAN         ____IN MEMORY
                                ____ TOGETHERNESS
PREFERENCES:
     ____ HEAD SHOT                     ____ FULL BODY
                                        
____ TEXT                                 ____ NO TEXT
TEXT:
_____________________________________COLOR_________
CHECK  IF  PHOTO  E-MAILED:____

PICTURE SIZE         QTY             COST              ADDITIONAL COPIES

8' X 10'                    _____           $ 20.00                          $ 10.00
5' X 7'                      _____           $ 15.00                          $   8.00
4' X 6'                      _____           $ 10.00                          $   5.00
WALLETS               _____           $
    2.00            20 FOR $ 30.00
_________________________________________________________ SUB  TOTAL                  $________
PA SALES TAX  6%      $________
SHIPPING/HANDLING  $________
TOTAL                           $________

NAME:___________________________________________________
ADDRESS:________________________________________________
PHONE #:  ________(
IN CASE WE HAVE QUESTIONS WITH YOUR PHOTO)NOT REQ.
E-MAIL:    _________(
IN CASE WE HAVE QUESTIONS WITH YOUR PHOTO)NOT REQ
PLEASE  SEND  CHECK  OR  MONEY  ORDER  PAYABLE  TO 
JOHN L SCHROLL III   TO
UNIQPIX
219A  BIG OAK RD.
DILLSBURG,   PA    17019
PLEASE  ALLOW 2-4 WEEKS  FOR  DELIVERY