Custom Rug Order

* Indicates a required field.

Custom Rug Order Sheet

Style #	Style Name	Color #	Color Name

Rug Binding

Rug Shape

Rug Size x (width x length)

Quantity

Comments / Extra Notes

First Name *

Last Name *

E-mail Address *

Phone Number *

Fax Number

Residential*

Yes No

Address* (must be a street address)

City *

State *

Zip Code *

Billing address same as shipping address

Credit Card Type

Name as it appears on card

Credit Card Number *

Expiration Date * / ( mm/yyyy )

You should receive an order confirmation within 24 hours. If you do not, please call us at 1-800-338-7811

You may also print this form and fax your order to us at 706-226-9061