Last Name:______________________________________

Address:__________________________________________ Apt#:_______________

City:__________________________ State:_______________ Zip Code:___________

Email:_______________________________________________________

Home Phone:______________________________

Work Phone:______________________________

Description of Repair:________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Shoe Size:__________

Shoe Brand and color:_________________________________________________________________________

Credit Card Type:__________________ Credit Card #:______________________________________________________

Exp Date: mo_____ year_____ 

3 Digit Security Code _________ (Visa, Mastercard and Discover located on back of card near signature)
                                                                  Note: We now gladly accept American Express

Print out this form, fill it out and send it along with your article that needs repair to:

George's Shoes and Repair
3673 Lexington Ave North
Arden Hills, MN 55126