Special Order Form

To Order Online

Fill out Our
Special Order Request Form

      * required entries

Full Name: *(Required)

E-mail Address: *(Required)

Street Address: *(Required)

City: *(Required)

State/Prov:

Postal Code: *(Required)

Country:

Daytime Phone Number: *(Required)

Any Special Instructions On Contacting You:

Special Order: *(Required)

Enter Order Needed: *(Required)

Name of Cemetery to Placed in*(Required) if not required put N/A

Address of Cemetery: *(Required) if not required put N/A

Telephone Number of Cemetery: *(Required) if not required put N/A

Burial Location of Deceased within Cemetery: *(Required) if not required put N/A

CONDITIONS and TERMS of PURCHASE
By submitting this order, I hereby agree that I have investigated and can validate
that this special order that I am ordering, conforms to all cemetery rules
and regulations or specifications held by the cemetery where it would be used. I
further agree to not hold Cemetery Broker responsible for any rejection of the
product I am ordering.

NOTICE: BY COMPLETING THIS ORDER FORM, PURCHASER HAS READ ALL
TERMS AND IS AGREEING ANY CLAIM PURCHASER MAY HAVE AGAINST
SELLER SHALL BE RESOLVED BY ARBITRATION AND PURCHASER IS
GIVING UP HIS/HER/THEIR RIGHT TO A COURT OR JURY TRIAL AS WELL
AS HIS/HER/THEIR RIGHT OF APPEAL.

I have read and I agree to the Terms and Conditions of Sale (Please click here)

You Will be Taken to Our Secure Payment Site if Ordering Online

Method of Payments

or

PayPal

**To Order By Fax or By Mail**

Please Fill Out Our
Special Order Request Form
above and this
Billing Form
and either
Mail or Fax It to Us

Bill this order to:

Name as it appears on the card:
Billing Address
Address line 2
City
State/Province
Zip Code
Card Number
Card Type	Please select one: Visa Master Card
Expiration Date	Day Month Year
CVV2	What is CVV2?(Click Here)
Select:	Please select one: I have entered my CVV2 above My card has no CVV2 imprint My cards' CVV2 is illegible

To Order By Fax

Mailing Address:
	John M. Harris Co. Cemetery & Funeral Consultants P.O. Box 2191 Hawthorne, CA 90251

Phone: 1-877-723-5677 | Fax: 1-775-599-8591 | Email: sales@cemeterybroker.com

www.cemeterybroker.com

To Order Online Fill out Our Special Order Request Form

To Order Online

Fill out Our
Special Order Request Form