SOUVENIR PRODUCT ORDER FORM - PRINT AND MAIL THIS ORDER FORM
Complete sign and mail order form with payment. Forms not signed will be discarded.
If field does not apply, leave blank. If you need additional fields, fill out custom field and print legibly…

Please use the fields below to include all information pertaining to your order. Information which is not relevant to your order will automatically be purged when your order is completed. Enclose any further info if needed.
SOUVENIR BIRTH:  $169.00  NOW ONLY $99.00 Add Genuine Original Raised Seal $US35.00
FULL NAME AS ON NOVELTY BIRTH CERTIFICATE :                             FIRST                                                         MIDDLE                                                LAST


DATE OF BIRTH:                                                    SEX:                                               PLACE OF BIRTH:                                            HOSPITAL:

MONTH/DAY/ CENTURY AND YEAR                            M/F                                                 CITY/COUNTY/STATE/COUNTRY
 

FULL MAIDEN NAME OF MOTHER:

FIRST                                                         MIDDLE                                                LAST 
 

FULL NAME OF FATHER:

FIRST                                                         MIDDLE                                                LAST  

SOUVENIR DEATH:  $169.00  NOW ONLY $99.00 Add Genuine Original Raised Seal $US35.00

LEGAL NAME OF DECEASED:                             FIRST                                                         MIDDLE                                                LAST

DATE OF DEATH:                                           COUNTY/COUNTRY OF DEATH:                                                SEX 


DATE OF BIRTH OR AGE:          RACE:                         NAME OF SPOUSE:                                            NAME OF PARENTS:

                                                                                                            
 

SOUVENIR MARRIAGE OR DIVORCE:  $169.00  NOW ONLY $99.00 Add Genuine Original Raised Seal $US35.00

FULL NAME OF HUSBAND:                              FIRST                                                         MIDDLE                                                LAST
 

FULL MAIDEN NAME OF WIFE:                        FIRST                                                         MIDDLE                                                LAST
 

DATE OF MARRIAGE:                                               (OR) DATE OF DIVORCE:
 

IF MARRIAGE, COUNTY, STATE COUNTRY OF CERTIFICATE:                                  IF DIVORCE, COUNTY, STATE COUNTRY OF DIVORCE:
 

YOUR SIGNATURE:

     Payment: US Funds US$99.00 + $15.00 Shipping & Handling Total Due: $108.00
Add Genuine Original Raised Seal AUD $45.00  GBP £35.00     EURO €35.00       US$35.00
 
RUSH ORDERS (CASH ONLY ) ADD  AUD $60.00  GBP £35.00  EURO €45.00    US$55.00
  

     Cash ___Or Traveler Checks___RECOMMENDED FOR FASTEST SERVICE  International Bank Draft or International Money Orders____ We DO NOT accept personal checks or US post office local money orders. We do accept US post office  INTERNATIONAL MONEY ORDERS All checks will be held for 30 days and order shipped after clearance.   

PLEASE SHIP MY SOUVENIR PRODUCTS TO MY ADDRESS BELOW!

Name:
 

Address:

City:

State/Province:

Zip:
 


Country:                         E-mail Address: _________________________________________   Phone Number: _______________________
 

Terms and Conditions:  I state, I am the person whom I represent myself to be herein, and I affirm the information within this product application is complete and accurate. I represent, warrant and covenant that: I am at least eighteen years of age and have the full right and authority to enter into this Agreement. I do not reside in any country to which import of souvenir design products are prohibited or restricted. I will not use any of the souvenir software designs in any manner prohibited by any laws, restrictions or regulations. My use of the souvenir design prints does not violate any applicable law or regulation of the country, state, or other   governmental entity in which I reside.  I shall be solely responsible for use of the original souvenir designs and agree that I must satisfy myself that all necessary rights or consents regarding any of the above, as may be required for reproduction, have been obtained. I agree I am solely responsible for determining whether my use of any souvenir software designs created for my own personal or business use requires the consent of any other party or the license of any additional rights. I without reservation or restriction understand fully that any souvenir product is not an authentication feature issued by or under the authority of any government, state, political subdivision of a state, a foreign government, political subdivision of a foreign government, an international governmental or an international quasi-governmental organization. I understand any souvenir software designs are not an official legal substitute for any product issued by any official government or administration or substitute for such. I understand all content on this Site, including, but not limited to, text, images, illustrations, audio clips, and video clips, is protected by copyrights, trademarks, service marks, and/or other intellectual property rights worldwide copyright laws and treaty provisions, privacy and publicity laws, and communication regulations and statutes. I understand you shall not be responsible for loss or damage to products for for delays in due to circumstances or causes beyond your control, nor do you assume any responsibility whatsoever for delay due to failure of transportation communication. I expressly acknowledge you reserve the right to change, modify, update or discontinue any design for any reason and elect to replace any design with an alternate design, and to suspend, cancel, terminate, grant or deny any product order at any time without notice. I agree to use all souvenir products in a lawful manner and not to violate the rights of others, or otherwise violate any applicable local, provincial, state, national or international laws. I understand you disclaim any liability for losses, damages, forfeitures of deposit or expenses, damages of any kind whatsoever incurred by in the event the product order applied for is denied or not obtained within a stated time period.  I acknowledge that the responsibility for the accuracy of the information contained in the applications is solely mine, and I hereby authorize on my behalf processing of any product order required by me through your affiliates, representatives or third party agencies.  I am ordering souvenir products for my own amusement, and understand and agree any souvenir product is not to be used for any official purpose, or to use, deal with or act upon it as if they were genuine, or to induce any person by the belief that it is genuine. I accept all responsibility for accuracy or release of information or contents of any souvenir product. I understand fees are non-refundable for any product, even if the request is denied by its official representative, and you reserve the absolute right to refuse service to any individual for any reason and does not have to provide reason. I agree to these terms and conditions. I understand all content is owned and controlled by the designers and affiliates, or by third party content providers, merchants, sponsors and licensors. I understand any third party agency may require a nominal fee for completion of any custom order, and I agree to pay this fee directly to the agency. I agree to abide by all additional copyright notices, information, or restrictions contained in any content. I understand that I may not copy, reproduce, republish, upload, post, transmit, distribute, and/or exploit any souvenir software design in any way for any official purpose. I understand you expressly disclaim any indication that you are an authorized dealer or agent of any of the designs whose products are featured on this site. The use or mention of any tradename, product name, image or trademark on your web site is in no way intended to suggest that the trademark owner is at all affiliated with or endorses your site. I understand all images are trademarks or registered trademarks of original designers, and are for reference only. I understand you do not provide any warranties of merchantability for a particular purpose, and you shall not be liable under any theory or for any damages suffered by me of any product I order. I further affirm and attest that my signature below serves as evidence that I, the bearer/purchaser, agree to the aforementioned agreement in its entirety. I understand that use of the souvenir software design content for any purpose other than personal, non-commercial, educational and amusement purpose, may violate local and international laws, the property rights and proprietary rights of the content owners and is prohibited. I fully understand that I may not use any registered or unregistered trademarks, design marks or copyrighted materials, including but not limited to any logos or characters, without the express written consent of the owner of the mark or copyright. I warrant and represent to you that I will not use any souvenir software design for any purpose that is unlawful or prohibited by these terms, and agree not to distribute or disclose the same to third parties for any official purpose. I agree that I will not alter, deface, photocopy, and reproduce any souvenir design software  image or template in any way shape or form for illegal use. I further agree to accept full and complete responsibility for the purchase, use or misuse of any souvenir product. I understand that you will not be responsible for any orders that are not filled correctly or mailed to any address not in my own name. 

By signing this agreement, I attest, affirm, and do hereby certify and acknowledge that I have read this agreement, understand it, and accept all the terms and conditions contained herein, and agree to be bound by its terms and conditions.

    
_______________________________       X
________________________________          _____________________    

 Name                                                       Signature                                        Date

NO FEDEX, UPS, USPS EXPRESS OR PRIVATE COURIER ACCEPTED. USE YOUR LOCAL POST OFFICE MAIL OR
Priority Mail or British Royal Express
FOR FASTEST SERVICE.
MAIL YOUR ORDER FORM AND PAYMENT TO ADDRESS BELOW:  If sending international money order or traveler checks  leave the 'Pay to:' / 'Payee:' / 'Pay to the order of:' field blank. Do not enter our mailing address on money order payee field  
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