Click on your Browser's "Print" button to print this form 

RETURN / ORDER FORM 
 PLEASE PRINT CLEARLY                                                                                  DATE___________________
Name:          
Address:           
City:    State   Zip  
RETURNING:  
Name of Shoe Size Style# Color Price Ea. Qty TOTAL
             
             
              
             
             
 
ORDERING:
Name of Shoe Size 1st Color Choice 2nd Color Choice Price Ea. Qty TOTAL
Style# Style#
             
             
             
             
             
 
Exchange Postage - Domestic Orders  $5.00
Exchange Postage - Intl. Orders    $37.00
Total Amount Ordered $  
Total Due Moccashoes $  
Check One   or  
Total Due Customer $  
Thank you,
PLEASE NOTIFY US IF YOU HAVE A CHANGE OF ADDRESS  
17161 Newport Club Dr. • BOCA RATON, FL 33496 
or Fax: 561-241-3982