Print this order form and send it to us with your repairs. Please include an order form with each pair that you are sending in for repair. Shipping & Handling is per order not per pair.

All prices are US dollars.


Ordered by (please print clearly)                                Ship To  (if different than ordered by)

Name_________________________                    Name_______________________

Address_______________________                    Address_______________________

City__________________________                    City__________________________

State_____zip code_______________                   State_____zip code_______________

Daytime phone Number_______________Evening phone number_____________E-Mail address_____________
shoe style name_______________color_______________size______ width_______

Circle the repairs needed for this pair:

Resole (regular sole)  $30.00 -- Reline (suede)   $25.00 (Some styles may require a resole) -- Recraft $65.00--

Footprint resole $65.00

shipping &handling (per order)    $ 7.50____Check Enclosed _____Charge my Credit Card

Order total                           $_______ Card Type: ___Visa ___Disc___Amex___Master Card

Card #____________________________________exp date________
--------------------------shipping label--------------------------------|

From
_____________________________
_____________________________
_____________________________

                                Grounded Soles-Repair Dept
                                3 N Second Ave
                                PO Box 56
                                Taftville Ct 06380-0056