11 July 2025
Repeat Customers: Please check
changed address? **_____  changed email address? **______

old address:_______________________________________________________________
SAMPUBCO BIOGRAPHIES ORDER FORM
Name (PLEASE PRINT):**_____________________________________________________

Email (REQUIRED!):**_______________________________________________________

Street/P.O. Box:**_________________________________________________________

City/State/ZipCode+4:**____________________________________________________
(out of USA - City, Province, Country, Postal Code)
Order (do *NOT* alter the information as listed onsite in any way):

Name of Person:      Record Source #: (copy entire line)
Example: DOE, JOHN   CT-1-50

1._________________________________________________________________________

2._________________________________________________________________________

3._________________________________________________________________________

4._________________________________________________________________________

5._________________________________________________________________________

6._________________________________________________________________________

Scanned ____ and/or PDF ____
Cost:
Sent by email
$3.00 per record if by PayPal/CreditCard
$5.00 per record if by check in mail
(if paying by credit card, please email order and request credit card invoice.)
Email address is sammyslc at gmail.com for sending this order as attachment and
for sending payment via PayPal.

Number of records: _______X USD $__.00 = __________
circle form of payment: check/moneyorder  PayPal  creditcard (invoice will be
sent upon request for PayPal and credit card only.)

MANDATORY INFORMATION TO KNOW:

Please do NOT staple or tape check to the order. Please do not combine with
other records.

Mail to:
W. DAVID SAMUELSEN
SAMPUBCO
P.O. Box 11874
Salt Lake City, UT 84147-0874