Gorjana Order Form — LORI BRUDZISZ

PAYMENTS CURRENTLY ACCEPTED VIA VENMO & PAYPAL

I WILL CONTACT YOU FOR PAYMENT UPON RECEIPT OF THIS FORM

THANK YOU FOR YOUR SUPPORT!

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Subject

Message

PLEASE INCLUDE: NAME OF PIECE COLOR/METAL (GOLD/SILVER/ROSE GOLD) QUANTITY