Mourninglights™ Order Form
Name:
Address:
City: State:
Zip Code:
E Mail Address:
Daytime phone number:
Ship to Address: Same
Name:
Address:
City: State: Zip Code:
Choose Your Light Type
Please choose either the free wax 15 hour votive or the 36 hour battery light for an additional $3. The battery lights have an on /off switch and the batteries are replaceable.
Wax
Pink 
Amber 
Address:
City: State:
Zip Code:
E Mail Address:
Daytime phone number:
Ship to Address: Same
Name:
Address:
City: State: Zip Code:
Choose Your Light Type
Please choose either the free wax 15 hour votive or the 36 hour battery light for an additional $3. The battery lights have an on /off switch and the batteries are replaceable.
Wax
Pink
Amber
Your inscription
Print your name in the text box below. (30 characters maximum please)
or
Use the space below to write a message which we'll include on a card at no extra charge. (100 characters maximum please)
Please write in the inscription boxes what you would like to appear on your mourninglight™. (30 characters maximum per line please)
Line one:
Line two:
A third inscription line is available for an additional charge of $3.00.
Line three:
Quantity:
Are you giving this mourninglight™ as a gift? Choose either to have your name printed on the reverse or a gift card at no extra charge.
A Gift fromPrint your name in the text box below. (30 characters maximum please)
or
Use the space below to write a message which we'll include on a card at no extra charge. (100 characters maximum please)