Fortuna's Shoe and Luggage Repair

Product Checklist

Please print this form and fill out the following information. Include this order form with your repair order.

Fortuna's
7835 Woodmont Ave.
Bethesda, MD 20814

If you should have any questions, please call us at (301) 654-2533 or e-mail us.

Date:_______

Customer:______________________________________________

UPS Address:___________________________ Apt./Ste:______

Business Name:_________________________________________

City:__________________ State:______ Zip:______________

Work Number: (___)-___-____ Home Number: (___)-___-____

Payment Information: Check__ Visa___ Master Card___

Card Number:__________________ Expiration Date:________

Signature:________________________

Please select the items and quantities you would like to order. We will email you the total cost before shipping!

Quantity:___ Barge Cement
Quantity:___ Buck Bag
Quantity:___ Dauber
Quantity:___ Desalter
Quantity:___ EZ Cleaner
Quantity:___ Leather Balm
Quantity:___ Leather Dye (Color_______)
Quantity:___ Leather Preparer
Quantity:___ Patent and Vinyl Cleaner
Quantity:___ Reptile Cleaner
Quantity:___ Shine Brush
Quantity:___ Shine Cloth
Quantity:___ Shoe Laces (Color_______)
Quantity:___ Shoe Trees
Quantity:___ Spot Remover
Quantity:___ Suede Renew (Color_______)
Quantity:___ Suede Stone
Quantity:___ Suede Stone
Quantity:___ Tinted Polish (Color_______)
Quantity:___ Toe and Heel Plates
Quantity:___ Water and Stain Protector

Send it to Fortuna's