Mail this form to:
Village Shoe Service
4286 Railroad Ave.
Tucker, GA 30084
Make your check payable to Village Shoe Service

TEL 770-938-7463 - www.villageshoeservice.com
Information we have about you is strictly guarded and used only to help us serve you better. We never share any of your information.
SHIP TO

Name ________________________________

Address ______________________________

City ____________________ State _________

Zip __________

Company Name __________________________
BILL TO
Required If Different Must Match Statement Address


Name ________________________________

Address ______________________________

City ____________________ State _________

Zip __________

Company Name __________________________

Credit Card Number ____________________________________ Expiration Date __________

Card Verification # _________ Required click here for help.

Cardholder Signature ________________________________________

Telephone # ______________________ Email __________________________
QTY ITEM # / DESCRIPTION SIZE & WIDTH UNIT PRICE TOTAL
         
         
         
         
         
         
         
         
         
         
Your Business Is Appreciated.