Order Form

GosiasBallrom.com

Facsimile Order Transmittal Sheet

To: Gosia		From:

Company: GosiasBallroom.com		Date:

Fax number: (510) 657-3149		Total no. of pages including cover:

Telephone: (510) 378-1365		Sender's Fax Number: Sender's Phone Number:

Re: Dress Order

This facsimile contains private information intended solely for the use of the recipient. If you receive this information in error, please forward it to its rightful recipient immediately. Thank you.

Dress Style No. Description Size Price Sales Tax (8.75% CA) Total

_______________________________________________________________________

Grand Total __________

Shipping Information:

Customer Name: _______________________

Shipping Address: ___________________________

___________________________

Telephone: ____________________ Day ____________________ Evening

Best time to reach: ______________________

Fax Number if Available: _________________

Billing Information:

Name: ____________________________________ (If paying by credit card, please state exactly as it appears on the credit card).

Please check here if the same as Shipping address: ___

Billing Address: _____________________________

_____________________________

Payment Type:

Visa ___

Master Card ___

Credit Card Number: _________________________ Expiration Date: ___________

Amount Authorized: ____________ Signature: _____________________________

Special orders require a 50% deposit to begin processing. The 50% balance is due when the dress is completed.

If paying by check, your order cannot be processed until the check has cleared. No third-party checks please.

Please mail your check or money order to:

GosiasBallroom.com

43333 Osgood Road

Fremont, CA 94539

Check ___

Money Order ___

Please fill out your measurements in inches or centimeters, as indicated below.

Thank you.

Neck _____ Shoulder to Shoulder Front ______

Shoulder to Shoulder Back ______

Around Bust ______

Waist _____

Hip (8 inches down from waist) ______

Wrist ____

Elbow ____

Bicepts ____

Skirt Length from Waist ______

Bust Point to Bust Point ______

Shoulder to Bust Point ______

Nape to Waist ______

Arm Length Outside ______

Comments: _________________________________________________________________

__________________________________________________________________________