Date: Company Name: Account #: Address: City, State, Zip: Phone #: Contact: Fax: Email: Direct Importers of Fine Gemstones Since 1955 ORDER FORM Fax#: 212-869-3080 Ph#: 1800-634-8497 Ph#: 212-869-5370 brad@stonemangems.com Quantity mm Size Shape Cut Type Name Quality Attributes                                                                                                                                                                                                 Payment By: Open Account   *   COD   *   Credit - (Amex) - (Visa) - (MasterCard) Credit Card #: Cardholder's Printed Name:                                                                                  Expiration Date: Cardholder's Signature: Cardholder's Billing Address: Requested Shipping Method: U.S. Postal, Ground, 3 Day, 2nd Day, Next Day, Other