Date:______________________________

Name:______________________________

Address:____________________________________________________________

City:______________________________ State:____ Zip:_______

E-mail_____________________________

Home Phone Number__________________________

Cell Phone Number__________________________

Number of Bears Ordered 16"______ 24"______

Should we include the memory poem? Yes     No

Description of clothing:_______________________________________________
_______________________________________________________________________
_______________________________________________________________________

**One 24" bear needs approximately 1 yard of material (36" by 45")
Special instructions:__________________________________________________
_______________________________________________________________________
_______________________________________________________________________

All Memory Bears come without eyes unless requested. Please check one. ___ No Eyes ___ Brown Eyes ___ Blue Eyes

Check one: Return extra material     Don't return extra material

Payment, (check or money order / no credit cards)
1/2 of total payment due with order
Balance due upon shipment.
Amount Enclosed_____________________