Statuette Order Form IndieFEST Statuette Order Form If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required. Date * First Name * Last Name * Email * Telephone * Complete this section for addresses in the United States Street Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code Complete this section for international addresses International Address Country * Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Of The Cook Islands Costa Rica Cote D'Ivoire Croatia (Local Name: Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Timor-Leste (East Timor) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard And Mc Donald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic Of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic Of Korea, Republic Of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, Former Yugoslav Republic Of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts And Nevis Saint Lucia Saint Vincent And The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia, South Sandwich Islands South Sudan Spain Sri Lanka St. Helena St. Pierre And Miquelon Sudan Suriname Svalbard And Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic Of Thailand Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis And Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe Film Name(s) * ****************************** INSTRUCTIONS Line #1 - Will be "IndieFEST Winner" (Completed by IndieFEST staff) Line #2 - Your level of award (Award of Merit, Award of Excellence, or Award of Recognition) (Completed by IndieFEST staff) In addition to Line #1 and Line #2 you have another six (6) lines to use. You do NOT need to use all six lines. NO MORE than 24 characters (including spaces) per line. ****************************** *************************** Statuette # 1 Line #1 Line #2 Line #3 Line #4 Line #5 Line #6 Line #7 Line #8 Statuette #2 Line #1 Line #2 Line #3 Line #4 Line #5 Line #6 Line #7 Line #8 Statuette #3 Line #1 Line #2 Line #3 Line #4 Line #5 Line #6 Line #7 Line #8 Statuette #4 Line #1 Line #2 Line #3 Line #4 Line #5 Line #6 Line #7 Line #8 Statuette #5 Line #1 Line #2 Line #3 Line #4 Line #5 Line #6 Line #7 Line #8 Statuette #6 Line #1 Line #2 Line #3 Line #4 Line #5 Line #6 Line #7 Line #8 Statuette #7 Line #1 Line #2 Line #3 Line #4 Line #5 Line #6 Line #7 Line #8 Statuette #8 Line #1 Line #2 Line #3 Line #4 Line #5 Line #6 Line #7 Line #8 Special Instructions Order Totals Total number of Statuettes * 0 = Order stickers only1 = $375 USD2 = $750 USD3 = $1125 USD4 = $1500 USD5 = $1875 USD6 = $2250 USD7 = $2625 USD8 = $3000 USD Total number Rolls of Stickers (100 per roll) 1 Roll - $40 USD2 Rolls - $80 USD3 Rolls - $120 USD4 Rolls - $160 USD5 Rolls - $200 USD International Shipping (shipping in USA FREE) 1 Statue - $65 USD2 Statues - $130 USD3 Statues - $195 USD4 Statues - $260 USD5 Statues - $325 USD6 Statues - $390 USD7 Statues - $455 USD8 Statues - $520 USD Sub Total Sales Tax: Purchases made within the State of California must include 9% sales tax. If you are not making your purchase within the State of California, USA please put a 0 here. * Total When you click the "submit" button - you will be taken to the secure PayPal website for payment. You can pay with a PayPal account or a credit card. When your transaction is complete - you will automatically be brought back to this page.
