G I B R O C K S   O R D E R   F O R M
               =====================================

Personal Details
================

      Full Name:_____________________________________________________

        Address:_____________________________________________________

           Town:_____________________________________________________

         County:_____________________________________________________

        Country:_____________________________________________________

Area Code (ZIP):_____________________________________________________

   Telephone No:_____________________________________________________


Products Required
=================
 ____________________________________________________________________
| Item *     | Code No.  | Qty | Size/Length |   Stone   |   Price   |
|------------|-----------|-----|-------------|-----------|-----------|
|            |           |     |             |           |           |
|___________ |___________|_____|_____________|___________|___________|
|            |           |     |             |           |           |
|___________ |___________|_____|_____________|___________|___________|
|            |           |     |             |           |           |
|___________ |___________|_____|_____________|___________|___________|
|            |           |     |             |           |           |
|___________ |___________|_____|_____________|___________|___________|
|            |           |     |             |           |           |
|___________ |___________|_____|_____________|___________|___________|
                                                         |           |
                                                 TOTAL   |___________|

* Under 'Item' please enter Ring, Earring, Bangle, Bracelet, Pendant,
Chain, Choker or Locket as appropriate.


Credit Card Details
===================
               _          _                _          _
Type of Card: |_| Visa   |_| Mastercard   |_| Amex   |_| Diners
          __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
         |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
Card No: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
                                                     __ __      __ __
                                                    |  |  |  / |  |  |
                                       Card Expiry: |__|__| /  |__|__|

     Cardholder Name:________________________________________________

  Cardholder Address:________________________________________________
    (if different)
    ( from above )   ________________________________________________



Cardholder Signature:________________________________________________