The Loft Violin Shop Sponge Shoulder Rest Order Form

New Colors... Same Density and Feel

Original Firm (Formerly Blue)

Select Soft (Formerly Gray)

1. Your Information

First Name *

Last Name *

Affiliation *

Individual

Company

School

Shipping Information *

U.S. Shipping

International Shipping

International Shipping Address and Phone Number *

Business Name

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Billing Address *

Same

Different

Billing Address 1 *

Billing Address 2

Billing City *

Billing State *

Billing Zip Code *

2. Your Loft Sponge Order

Original Firm (Formerly Blue) Loft Sponge Shoulder Rest

	Original Firm # 2 (fits 1/32 - 1/10)
	Original Firm # 3 (fits 1/8 - 1/4)
	Original Firm # 4 (fits 1/2- 3/4)
	Original Firm # 5 (fits 3/4- 4/4)
	Original Firm # 6 (fits 4/4)

Select Soft (Formerly Black) Loft Sponge Shoulder Rest

	Select Soft # 2 (fits 1/32 - 1/10)
	Select Soft # 3 (fits 1/8 - 1/4)
	Select Soft # 4 (fits 1/2 - 3/4)
	Select Soft # 5 (fits 3/4 - 4/4)
	Select Soft # 6 (fits 4/4)

Total before Tax (if applicable) and Shipping

$0.00

For individual/retail orders, please allow for shipping and handling:

• $4.00 on orders of 10 or fewer
• $5.50 on orders of 11 – 24
• Free shipping for orders over 25

• International Shipping will vary

3. Payment Information

Payment Method

Please Bill Me

Credit Card

Purchase Order

PO#

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

Security Code *

Additional Instructions: