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Name: ________________________________
Address: ______________________________
City: ________________ State: _______________ Zip: ___________
Shipping
Address: _____________________________________________
City: ________________ State: _______________
Zip: ___________
Tag/License Number: ___________________________________________
County Harvested: ____________
State Harvested: _________________
Date Harvested: _____________ Species: _______________________
Phone Number: (_____) _________________
E-mail Address: ________________________________________________
Description
(please include any damage including broken tines, missing teeth, etc.)
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Please choose from the following (circle one):
1. Whitened and clear coated
Yes No
If yes, please choose
the finish Matte Finish
Gloss Finish
2. Plaque Mount
Yes No
If yes, please choose
the type Oak
Walnut
Please specify if you would like a wall mount or a desk mount in either
one of these finishes.
Deposit Amount: $ _____________
Signature: __________________________________
Date:_________________
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