Belt Order Form Date: ______These are handmade and hand engraved. They are 3-1/8” x 4-1/8” and are designed with rope edge and raised banners. The raised banners have your initiation year, name, stud number, chapter name and school name. Twelve (12) letters are included for your chapter name and school. Each additional letter is $0.40. Twenty (20) is the maximum number of letters for school name. Rhinestones of any color can be added in flowers at each side for an additional $8.00.

A photo of a buckle is below. In the blanks beside it, please clearly write the information you’d like displayed on your belt buckle. Delivery takes approximately eight weeks.

Example: Your Belt Buckle: Name Name: ______Pin # Pin #: ______Rhinestone flowers (Red) InitationY ear: ______Chapter Name: ______Nameof School: ______Initation Year Rhinestone flowers? Yes No If yes, which color? ______Chapter Name Which style buckle? Nickel ($175) Silver Overlay ($300) Name of School ($350)

Please Print

Name: ______Chapter: ______Address: ______City: ______State: ___ Zip: ______Shipping Address: ______City: ______State: ___ Zip: ______Daytime Phone: ______Email: ______Payment Method (payment must accompany all orders): Check VISA Mastercard Name on Card (please print): ______Account Number: ______- ______- ______- ______Expiration Date: _____ /_____ Month Year CVV (three number code on back of card):______Signature: ______

Send order to: Shipping & Handling Alpha Gamma Rho Fraternity Actual shipping charges apply to 10101 NW Ambassador Drive Golden Crescents - call for amount. Kansas City, MO 64153 $ 5.00 or less: $ 1.50 or by fax to: 816-891-9401 $ 5.01 - $ 15.00: $ 2.75 or via email: [email protected] $ 15.01 - $ 25.00: $ 4.50 $ 25.01 - $ 50.00: $ 6.00 For more information on ordering, please contact: $ 50.01 - $150.00: $ 8.50 Judy Schmuecker, Director of Finance $150.01 - $200.00: $10.00 [email protected] $200.01 and up: $12.50 816-891-9200 ext. 13