Name___________________________________
Date_________________
Address_________________________________
City__________________________ State__________ Zip Code________ Country____________
Area Code and Phone Number (____)______________ E-Mail Address___________________________
Wearers Name or Initials_____________
Short Description of System sent to Duplicate ___________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Hair Type Desired: Human Hair___ Synthetic Fiber___
Style: Please indicate one:

Wave Or Curl Pattern: (examples) Body Wave___ Slight Wave___ Medium Wave___Tight Wave___ Medium Curl___ Tight Curl___
Finished Hair Density: Light___ Medium___ Heavy___ Other___________________
Finished Hair Length:_____ (Maximum finished length is 5" with no extra charge)
Match color to System Yes___ No___
Scotch Tape Large Hair Samples in appropriate boxes. (how to take hair samples)

2 LEFT TEMPLE . . .

4 BEHIND LEFT EAR . . .

2 RIGHT TEMPLE . . .

4 BEHIND RIGHT EAR . . .

1 FRONT . . . .

3, 5 TOP . . . .

6 BACK . . . .

Special Requests: ________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Quantity Ordered               _____    Additional charge for longer finished lengths.
Price of First System Ordered $249.99   Add $20.00 Ea. for 6" to 7" Finished Length
Second System $199.99         $_____    Add $30.00 Ea. for 8" to 10" Finished Length
Additional Charges            $_____    Add $50.00 Ea. for 11" to 12" Finished Length
Miscellaneous Supplies        $_____    Add $70.00 Ea. for 13" to 14" Finished Length
Total System Charge           $_____    Add $90.00 Ea. for 15" to 16" Finished Length
                                        Add $50.00 Ea. for 28 day rush delivery

Please include $13.40 for UPS-Ground shipping.  UPS 2 Day Air and Overnight shipping is additional.
Please make all checks and money orders payable to "New Look Hair Replacements"
Credit cards will be charged when the order is shipped.-----------------------------------------------------------------------------
To Pay By Credit Card - Visa____  MasterCard____  Amex____  Discover____  Call Me____
Exact Name on Card__________________________
Number____________________________  Expiration _______ Verification Code _____
Signature_________________________    Date__________________