eMilitaryCoins.com - military challenge coin order form
Print this form , complete all information, and fax to 623-266-7318 or print and mail to: eMilitaryCoins.com - 1067 E US Highway 24, #261, Woodland Park, CO 80863-2120

Quantity of coins: ______________ (You can always increase your order, but only before your final approval of the artwork or sample coin.)

MANUFACTURER: ____ China ____ South Korea ____ USA

Coin size:         1.56"         1.75"         2"         2.25"         2.5"         2.75"         3"         3.25"         3.5"         4"         Special shape (size_____")

Metal plating:   Antique Bronze          Antique Copper          Shiny Silver          Antique Silver          Matte Silver          Shiny Gold
                              Antique Gold          Matte Gold          Nickel          Matte Nickel          Black Nickel          Rhodium          Imitation Rhodium

Color Fill:   None          1 side (5 or less on one side)          2 sides (5 or less colors per side)

Extra colors: How many? ________ (If silk screening is desired, please circle silk screening and place the number of colors as extra colors.)

Features: (Please circle or check those that apply for your coin.)          KEY CHAINS

   EPOXY: ____ 1 side ____ 2 sides          SANDBLASTING: ____ 1 side ____ 2 sides          CUTOUTS: ____ (How many?)

   NUMBERING          LASER ENGRAVING - # of characters
____ (EDGE of coin, or FACE)

   TWO TONE PLATING         GROUND OFF LETTERING         ____ 4MM Thick

    PICTURE COIN INSERT: ____ 1 side ____ 2 sides          SILK SCREENING (for small non-paintable areas)

   Special paint:   PEARLESCENT            GLOW          HEAT CHANGING          TRANSPARENT #

   Edging:      ____ REEDED EDGE          DIAMOND CUT EDGE: ____ WAVE   ____ SWIRL   ____ SIDE  
                     ____ 3D ROPE EDGE          DIAMOND CUT EDGE: ____ ROPE   ____ PETAL   ____ Curve WAVE

    Presentation:   # ____ PLASTIC CAPSULES (25 minimum purchase)          # ____ VELVETEEN BOX (Blue, Red or Black - 25 minimum purchase)         
                      ____ RF Sleeve (100 min)  

Customer ID________________________________ (leave blank if unknown)      

____ New Order   ____ Reorder           Amount Being Charged:$______________       Promo Code:_______________________________

ORDER TYPE: ____ REGULAR w/sample coin          ____ REGULAR, NO sample coin           ____ RUSH ORDER (additional fees apply)

Credit card#:
Exp Date:

Name on card: ___________________________________________________          Notes:___________________________________________________ 

Billing address: __________________________________________________          ___________________________________________________ 

                                      __________________________________________________          ___________________________________________________

                                      __________________________________________________          ___________________________________________________

Shipping Address: (POC) __________________________________________________          BLIND ____

                                                                (Same?___) __________________________________________________


Telephone Number: (day)_____________________________ ( ____ evening or ____ cell)_____________________________

e-mail address for receipt of payment:, only one email per line          e-mail address for artwork approval: (Same?____)


By signing this order form, you certify that you are authorized to sign the debit or credit card listed above, that you have read and agree with the terms of service as listed on our web page at http://emilitarycoins.com/knowmore/legal_policy.php, that you agree to have the above credit or debit card charged for the merchandise placed by this order, and if applicable, all artwork, cancellation and die fees as explained more fully in the terms of service.

Signature:_________________________________ Printed name:_________________________________ Date:___________________