BRAZOS STAMP & ENGRAVING, INC. Self-Inking Daters

1407-D South 31st Street (Pecan Plaza) Temple, TX 76504-6719 (254) 774-7702

Fax: (254) 771-1982

www.brazosstamp.com

Self-Inking Stamps

Pre-Inked Stamps

Self-Inking Stamps

A COMPLETE LINE OF MARKING AND SIGN PRODUCTS MaxStamp Self-Inking Stamps, MaxLight Pre-Inked Stamps, PSI Self-Inking Stamps, Daters, Engraved Signs, Nameplates, Name & Logo Badges, Vinyl Lettered Signs, Banners and much more!

FAST SERVICE Phone # (254) 774-7702

Fax # (254) 771-1982 Toll Free Fax# 1-800-234-7110 www.brazosstamp.com

Catalog contents Type Style Chart

2

MaxLight Pre-Inked Stamps

3-4

PSI Self-Inking Stamps

5

MaxStamp Self-Inking Stamps

6-7

PSI Daters/MaxLight XL2 Daters

8

Trodat Printy Line/Cooke Time Daters

9

Flat Band Daters

10

Hand Stamps

11

Notary Seals

12

Engraving

13

Awards & Recognition Products/Banners & Signs

14

We can fill all your marking device needs. Please call for pricing on any items that you do not see in the catalog.

Refill Ink Using premium quality Maxum & MaxLight Stamp Ink ensures clean, crisp and fast drying impressions. Available in 1/4 oz. and 2 oz. Please specify color of ink when ordering.

2 oz 1/4 oz

$12.00 $5.00

Maxum Ink $3.00

Ink Colors Blue Green Red Purple Black

1

Brazos Stamp & Engraving, Inc. Phone: 254-774-7702 • Fax: 254-771-1982

Typestyle chart

Please Choose Type Styles By Number 200- FRENCH SCRIPT

201- EDWARDIAN SCRIPT

204- TIMES NEW ROMAN

205- SCRIPT

Mr. & Mrs. John Smith 1234 S. Main Street Temple, Texas 94567 Mr. & Mrs. John Smith 1234 S. Main Street Temple, Texas 94567

207- ARIAL BLACK

208- COMIC SANS

Mr. & Mrs. John Smith 1234 S. MAIN STREET TEMPLE, TEXAS 94567

Mr. & Mrs. John Smith 1234 S. Main Street Temple, Texas 94567

210- BOOK ANTIQUA

211- AVANT GARDE

Mr. & Mrs. John Smith 1234 S. Main Street Temple, Texas 94567

Mr. & Mrs. John Smith 1234 S. Main Street Temple, Texas 94567

212- OUTLINE

PAID

PAID

213- BANK GOTHIC

214- COPPERPLATE

215- FUTURA

Mr. & Mrs. John Smith 1234 S. Main Street Temple, Texas 94567

Mr. & Mrs. John Smith 1234 S. Main Street Temple, Texas 94567

These type effects are available for most of the above fonts:

SIZE

8

5/64”

APPROXIMATELY 14 LETTERS PER INCH

10

3/32”

APPROXIMATELY 11 LETTERS PER INCH

12

1/8”

APPROXIMATELY 9 LETTERS PER INCH

14

5/32”

APPROXIMATELY 8 LETTERS PER INCH

16

11/64”

APPROX. 7 LETTERS PER INCH

18

3/16”

APPROX. 6 LETTERS PER INCH

24

1/4”

AP. 5 LETTERS PER INCH

5/16”

AP. 4 LETTERS PER

48

209- ABADI CONDENSED

Mr. & Mrs. John Smith 1234 S. Main Street Temple, Texas 94567

PTS

36

206- ARIAL Mr. & Mrs. John Smith 1234 S. Main Street Temple, Texas 94567

Sample Type Sizes & Styles

30

203- CURLS

3/8”

1/2”

AP. 3 LETTERS P

AP. 2 LETTER

THIS IS PLAIN THIS IS BOLD THIS IS ITALICIZED THIS IS UNDERLINE THIS IS OUTLINE THIS IS SHADOW THIS IS UPPER CASE

THIS IS OUTLINE This is Upper and Lower Case

THIS IS SHADOW

this is lower case

Brazos Stamp & Engraving, Inc. Phone: 254-774-7702 • Fax: 254-771-1982

2

MaxLight XL2 pre-inked stamps The ultimate in pre-inked stamps has arrived! MaxLight XL2 Pre-Inked Stamps provide unsurpassed impression quality. No ink pad is needed - the ink is already in the stamp! Create thousands of impressions, remove the handle to add a few drops of ink to create thousands more. MaxLight XL2 Pre-Inked Stamps are so durable, they come with a lifetime warranty!

XL2-55

$21.95

EMERSON UNLIMITED CORPORATION 3/16” x 2-1/2”

XL2-75

$23.95

REALTY SERVICES 836 BARRINGTON RD. SCHAUMBURG, IL 60061

XL2-185 JANET CAROL TOM DONALD

25,000-50,000 clear impressions No ink pad needed 5 different ink colors Custom artwork & logos available Re-inkable Made in the U.S.A. Lifetime Guarantee Easy to re-ink! Just pull off the handle and apply a few drops in the top.

$36.95

RON BETH SUSAN PETER 15/16” x 2-3/4”

1/2” x 1-11/16”

XL2-115

• • • • • • •

$26.95

XL2-225

MR. & MRS. JOHN SMITH 1234 S. Main St. Mayville, CA 94567

$79.95

CASTLE CHIROPRACTIC

11/16” x 1-15/16”

XL2-125 $31.95 PAY TO THE ORDER OF FIRST BANK OF COLUMBUS FOR DEPOSIT ONLY EASTERN DATA SYSTEMS 736-4563-21

800 S.E. NORTHWEST HIGHWAY PALATINE, IL 60067 PH. (847) 991-1800 FAX (847) 991-1801

1” x 2”

XL2-145

2” x 3” $32.95

CONFIDENTIAL 5/8” x 2-3/8”

XL2-165

$39.95

Harbor Heights Inc. 910 Fox River Dr. Newland, Oregon Phone 374-888-4554 Fax 374-888-4555 www.harborheights.com

XL2-245

$61.95

TOURS INTERNATIONAL 13233 BALL ROAD BUENA PARK, CA 90000 (415)988-3333 1-1/4” x 3-3/16”

XL2-265

$38.95

IMPORTANT! Department manager must initial below before further processing. DEPT:

DATE:

1-1/2” x 2-1/2”

3

Brazos Stamp & Engraving, Inc. Phone: 254-774-7702 • Fax: 254-771-1982

MGR: 11/16” x 3-5/16”

MaxLight XL2 pre-inked stamps XL2-700 $92.95

ADDRESS INFORMATION CHANGE

NAME:_________________________ COMPANY:______________________ XL2-275 $79.95 NEW ADDRESS:_________________ FOR EMPLOYEE USE ONLY _______________________________ Distribute this information to all department CITY:___________________________ heads in accordance to the rules and regulations as in the company handbook. Please read STATE:__________ written ZIP:___________ all information carefully. Sign and date the top NEW PHONE #:__________________ copy and keep the white copy for future referNEW FAX #:_____________________ 2-3/4” x 3-3/4”

ence. Please return the pink copy to management as soon as possible.



1-7/8” x 3-7/8”

XL2-750

XL2-800

▲ $84.95

$124.95

NAME

PHONE NO.

STANDARD MARKING ADDRESS SYSTEMS, INC. DEPT. APPROVAL

CITY

STATE

ZIP CODE

VOUCHER #:

COMPANY: COMPANY

OWNER

STATE

DEPT.

SUPERVISOR

DATE:

COMPANY

DATE:

DEPT.

AMOUNT:

1-1/2” x 4-3/4”



XL2-655 2” Round ▲ $49.95

1-3/16” Round

INS PE

NT OU

$17.95



5/8” DIA.

ION M CT No. 174659

495 1-3/16” TH

7/16” Round

325

NT

XL2-305 #37

ION M CT

OU

$20.95



John W. Williams

E

DIA.

IS

$31.95

XL2-325 5/8” Round ▲

2 oz $12.00 1/4 oz $5.00 Maxum Ink $3.00

LIC E

XL2-495

Don’t forget to order your refill ink when you place your order!

T



ED ARCHIT NS

EC

3-1/8” x 4-1/2”

CHECK #:

IN SPE

PAID DATE:

O ST ATE LIN OF IL

▲ XL2-535 1-5/8” Round $44.95

Brazos Stamp & Engraving, Inc. Phone: 254-774-7702 • Fax: 254-771-1982

4

PSI

™ self-inking stmps stamps

Easy to re-ink! Just slide die box out by pushing from one end, and place a few drops in each hole.

Premium Self-Inkers™ (PSI™) are perfect for many applications, giving you thousands of high quality impressions without re-inking. PSI™ last two to three times longer than traditional self-inkers. They are extremely smooth and quiet in operation.

PSI 1919

$21.95

PSI 1444

OK 3/4” x 3/4”

$22.95

SHIP NEXT DAY AIR

▲ PSI 1854

1/2” x 1-3/4” $24.95

11/16” x 2-1/8”

PSI 1479

$26.95

APPROVED FOR SHIPPING Martin J. Phillips, Traffic Manager 9/16” x 3-1/8”

PSI 2773

Suburban Bank & Trust 280 S. Roselle Road For Deposit Only Acct # 5421545421



13/16” x 2-1/2”

PSI 3255

Please Keep Originals On File 1-1/16” x 2-7/8”

PSI 4141





PSI 2264 $28.95 PAY TO THE ORDER OF

$30.95

DUPLICATE ARTWORK



$29.95

PAY TO THE ORDER OF FIRST BANK OF COLUMBUS FOR DEPOSIT ONLY EASTERN DATA SYSTEMS 736-4563-21

$36.95

1-1/4” x 2-1/4”

PSI 3679



$36.95

U R G E N T Please Respond Immediately!

1-5/8” x 1-5/8”



We need to hear from you soon. Your subscription has expired & we don’t want any delay in service. 1-7/16” x 3-1/8”

5



Brazos Stamp & Engraving, Inc. Phone: 254-774-7702 • Fax: 254-771-1982



MaxStamp self-inking stamps MaxStamp Self-Inking Stamps are perfect for many applications, giving you thousands of high quality impressions without re-inking. The new aesthetically pleasing design incorporates center springs, Slide & Guide™ and rubber feet to create remarkably consistent impressions. Packaged with a large label and has a

To Replace or Re-Ink MaxStamp™ Self-Inking Stamps... Push the top of the unit down approximately 1/8”. Push the buttons (located on each side) inward to lock the unit in place. Push the pad out from either side. Replace the old pad or apply Maxum® ink to the face of the old pad. Allow 5 minutes to soak in and insert back into the self-inker. Press down on the top of the unit and the locks release automatically. Use Maxum® or equivalent rubber stamp ink only.

new, rubber handle! PUSH

Lock

SI-10

$16.95

SHIP NEXT DAY AIR 9/16” x 1-1/2”

SI-15

$19.95

APPROVED FOR SHIPPING Martin J. Phillips, Traffic Manager 7/16” x 2-3/4”

SI-25 SI-20

NO EXCHANGES AFTER 30 DAYS FROM PURCHASE DATE

$19.95

Greg Stevens

11/16” x 3”

2521 Greenleaf Schaumburg, IL 50194

SI-35

3/4” x 1-15/16”

SI-30

$26.95

DUPLICATE ARTWORK

$22.95

PAY TO THE ORDER OF Suburban Bank & Trust 280 S. Roselle Rd. For Deposit Only Acct# 01234567

Please Keep Originals On File 1-1/8” x 2-3/4”

15/16” x 2-3/8”

SI-40

$22.95

SI-50 $33.95

URGENT Please Respond Immediately! Your subscription is about to expire. To avoid any delay in service, we need to hear from you now!

$28.95

FRAGILE MATERIAL PLEASE SHIP WITH THIS SIDE UP 1-9/16” x 2-3/8”

1-1/2” x 3” Brazos Stamp & Engraving, Inc. Phone: 254-774-7702 • Fax: 254-771-1982

6

MaxStamp self-inking stamps To Replace or Re-Ink MaxStamp™ Self-Inking Stamps... Push the top of the unit down approximately 1/8”. Push the

Round S.I.’s

C-12

$14.95 Impression Area: 1/2” Round

buttons (located on each side) inward to lock the unit in place.

NSP

I

Push the pad out from either side. Replace the old pad or

2003 B

apply Maxum® ink to the face of the old pad. Allow 5 minutes

2B

to soak in and insert back into the self-inker. Press down on the top of the unit and the locks release automatically.

C-17

$16.95 Impression Area: 11/16” Round

2B

Lock

Round Daters

NSP

I

Use Maxum® or equivalent rubber stamp ink only.

2003 B

C-30

$20.95 Impression Area: 1-3/16” Round

C-30/D

$32.95 Impression Area: 1-3/16” Round

C-43/D

JAN 12 2008

L RIVE L A

DUE

C-43 $34.95 Impression Area: 1-5/8” Round

R

F

$41.95 Impression Area: 1-5/8” Round

M

IA L LIB

A

ME

DATE OR

RY

JAN 12 2008 R

C-50/D

$49.95 Impression Area: 2” Round

C-50

$42.95 Impression Area: 2” Round

JAN 12 2008

7

Brazos Stamp & Engraving, Inc. Phone: 254-774-7702 • Fax: 254-771-1982

2B

PSI

™ daters

Premium Self-Inking™ (PSI™) Daters are here.

They are

extremely smooth and quiet in operation. PSI™ Daters utilize 2000 Plus* equivalent pads and make awesome impressions.

M600 M100 1 & 2 color - $49.95

APPLICATION

All Maxum® metal framed self-inkers

JAN 19 2009

JAN 19 2009

RECEIVED

are available with dates or 6 figure bands

15/16” x 1-11/16”

M800

1 & 2 color - $79.95 1-3/8” x 2-5/16”

SHIPPED

M300

DRAWING COMPLETED

JAN 19 2009 JAN 19 2009

METHOD OF PAYMENT CREDIT

C.O.D.

1 & 2color - $89.95

MONEY ORDER

ROBERT T. SVEC MANAGER DESIGN CAD UNIT 1 & 2 color - $69.95 1-3/16” x

1-7/8” x 2-1/16”

1-13/16”

MaxLight Z daters The new, outstanding Z Dater is the first in it’s family. Made to outlast any pre-inked dater out there, this dater takes impression

Z20

Drawing Completed

quality to the next level. With easy-to-turn wheels and no-mess handling, this pre-inked dater is sure to solve your everyday dating needs.

JAN 01 2010

Graphics Department 1 & 2 color - $78.95

Z30

1-7/16” x 2-1/4”

SHIPPED JAN 01 2010 5/8” ALL AMERICAN COMPANY ANY RETURNS MUST BE MADE BEFORE THE DATE LISTED ABOVE.

1-3/4” x 2-1/2”

1 & 2 color - $93.95

Brazos Stamp & Engraving, Inc. Phone: 254-774-7702 • Fax: 254-771-1982

8

Trodat printy line ®

• The original Trodat Printy Die Plate Dater • Minimum 10 years on date band • All models standard w/Black pad • 4750 & 4850 standard with Blue/Red pad • Other color pads available

4750

47.50

APPLICATION JAN 19 2005

RECEIVED

Cooke time daters

1” x 1-5/8”



Cooke NO. 4 Rotary Dater is one of America’s most popular dial rotary daters! Proven by years of heavy-duty use, Just turn the dial to change the dates, no gears to wear out. A frequent request by industry, banks and retail stores.

Cooke NO. 22 Rotary Dater is asked for by banks, retail stores and industry. This dater is ideal for hard, continuos service. The outside dial carries the days of the month from 1 to 31. Perfect for use in PAID or RECEIVED markings. Any custom wording can be put on center dial

9

Brazos Stamp & Engraving, Inc. Phone: 254-774-7702 • Fax: 254-771-1982

Flat Band daters

For years of perfect impressions, Flat Band Die Plate Daters are the finest available. These daters are built with careful attention to quality and detail. The heavy-duty die plates can withstand years of heavy use. Price plus $2.50 per line.

MaxStamp 401-1/4

A

MaxStamp 401-1/2

CREDIT DENIED

PAID IN FULL

JAN 19 ‘09

JAN 19 ‘09

Mr. B’s T.V. & Stereos

Super City Foods #234

A

1-1/4” x 1-1/4”

1-1/4” x 1-1/2” 1 & 2 color - $16.50

1 & 2 color - $16.50

MaxStamp No. 1

MaxStamp DBD 1-1/4

COUPON

CERTIFIED

JAN 19 2009

JAN 19 ‘09

Al’s Super Foods #234

ORIGINAL FACTORY PARTS-BUILD #45234

A

B

1-1/4” x 1-1/4”

1 & 2 color - $14.50

MaxStamp # 4

MaxStamp No. 2

-HEALTH ADVISORY-

RETURN MATERIAL ON OR BEFORE

PERISHABLE DISCARD AFTER

JAN 19 ‘09

JAN 19 ‘09

JOHNSON COUNTY PUBLIC LIBRARY C

1-1/4” x 2” 1 & 2 color - $19.50

KILGORE MEATS, INC. WILL NOT ACCEPT RESPONSIBILITY FOR SAFETY OF PRODUCT AFTER DATE INDICATED ABOVE.

1-1/2” x 2” 1 & 2 color - $21.50

D

2” x 2” 1 & 2 color - $23.50

A

Letter indicates Ink

Ink Pad Dishes create eye catching two-color impressions while

Pad Dish size for that

giving your dater a home base. Most Die Plate Daters are available

Die Plate Dater.

with a pad dish. Be sure to indicate the size desired when ordering.

Brazos Stamp & Engraving, Inc. Phone: 254-774-7702 • Fax: 254-771-1982

10

Hand stamps

• Inking requires separate stamp pad • For the “traditionalist” • Long-lasting rubber die

Lines of Copy

Price

First Line Each Additional Line

$5.50 2.50

Each line of copy set in type over 1/4” (20 pts.) in height will be charged as 2 lines. For camera-ready art, each 1/4” in height is charged as 1 line of copy. Please call for prices on hand stamps over 3” in height and/or 6” in length.

Ink Pads We offer a wide range of sizes and colors. Our pads utilize the highest quality felt available to ensure excellent ink transfer. Available inked In a variety of colors: Black, Blue, Red, and Green Ink. We also offer Dry pads, Cloth Marking Ink, Quick Drying Ink (for back of photos). Special Ink Colors Available!

Pad # 00 0 1 2 3

Size 2” x 2-3/4” 2-1/4” x 3-1/2” 2-3/4” x 4-1/4” 3-1/8” x 6-1/8” 4-5/16” x 7-3/8”

Price $2.25 3.25 3.75 4.50 9.60

Need something you don’t see? Contact us for all your marking needs including re-banding daters and re-mounting dies.

11

Brazos Stamp & Engraving, Inc. Phone: 254-774-7702 • Fax: 254-771-1982

Notary seals

Pr ofessional & Custom Seals

A full range of professional and personal seals are available. All seals are engraved to meet the exacting specifications of all local, state, and federal regulations. Custom seals can be individually designed by our staff, or taken directly from your camera-ready artwork.

Pocket Seal Pocket Seals offer a heavy duty frame and precision parts for the finest impressions every time. Easy sliding lock mechanism makes for convenient handling and storage. Available round impression areas are 1-5/8” and 2”; as well as a rectangular 1’ x 2’.

Desk Seal Our Desk Seal is designed to produce embossed impressions with minimal effort. Easy sliding lock mechanism makes for convenient handling and storage. The Desk Seal accommodates the same die holders as the Deluxe Pocket Seal: 1-5/8” 2” round and 1’ x 2” rectangular. Item # Pocket Seal Pocket Seal Pocket Seal Desk Seal Desk Seal Desk Seal Seal Only

Size 1-5/8” Round 2” Round 1” x 2” 1-5/8” Round 2” Round 1” x 2”

Retail Price $34.95 $42.95 $34.95 $39.95 $44.95 $39.95 $29.95

All impressions are available as embossers or notary stamps.

Brazos Stamp & Engraving, Inc. Phone: 254-774-7702 • Fax: 254-771-1982

12

Engraving

Custom Architectural & ADA Signs Our engraved Architectural Signage is designed to

No. CA14 ▼ 1 3/4” x 4 1/8”

meet your exacting specifications. All signs are available

No. CA66 ▼

framed with square or round corners. Frames are No. CA413 ▼

available in five stock colors: Black, Brown, Gray, Almond & White. Call for special colors and sizes. Signage can be made with attached raised braille lettering to comply with the Americans with Disabilities Act. Frames for regular Architectural

4 1/8” x 13 1/8”

6 1/8” x 6 1/8”

No. CA19 ▼

Signage and ADA Compliant Signage are fully interchangeable.

1 3/4” x 9 1/8”

No. SS210 Slider Sign ▼

2” x 10”

No. CA99 ▲

9 1/8” x 9 1/8”

Important To Remember When Ordering: • Sign Size • Sign Color • Letter & Braille Color • Letter Style • Holder Color • Mounting Method

Custom Desk Plates & Name Tags

Black / White

STOCK COLORS

White / Black

Brown / White

Gray / White

Walnut / White

Red / White

Silver / Black

Blue / White

Yellow / Black

Green / White

White / Blue

Maroon / White

White / Red

Call for Sign Quotes...1-254-774-7702

Engraved Letter Styles Full Color • Helvetica Medium Custom Nametags • Helvetica Bold • • • •

Ultra

Helvetica Italic Times Roman News Gothic

Script Fastener Types

Acrylic Base

Standard Holder

Clip

No. UL01 1-3/4" x 9-1/8"

Acrylic or Wood Base No. AC01 No. AC02 No. WD01 No. WD02

No. SH01 No. SH02

1-1/2” x 3”

No. CB01

1-1/4” x 3”

3/4” x 2-1/2”

1” x 3”

1” x 3”

Engraved Custom Nametags Brazos Stamp & Engraving, Inc. Phone: 254-774-7702 • Fax: 254-771-1982

2" x 8" 2" x 10"

Wall Mount No. WM1 No. WM2

13

2" x 8"

Walnut Block No. WB01 No. WB02

Double Sided

2" x 8" 2" x 10"

Walnut Block with Card Holder

Magnet Bar

Wall Mount

2" x 8" 2" x 10" 2" x 8" 2" x 10"

Standard Holder

Pin

Walnut Block & Card Holder

Ultra

2" x 8" 2" x 10"

Double Sided No. DS01 No. DS02

2" x 8" 2" x 10"

Awards & recognition products Our recognition products help dress up your

office & are great for pointing out special achievements. All items are available in a variety of shapes & sizes, and they are engraved to your exact specifications. For more information visit us on the web www.brazosstamp.com

Banners & signs

Acrylic Award Laser Engraving Award Plaque Cast Bronze Plaques Etched Brass Laser Marble

We can manufacture many types of custom signs. Vinyl, Magnetic Vehicle Signs, Parking Signs Banners and much more! Call us today to discuss your needs.

Brazos Stamp & Engraving, Inc. Phone: 254-774-7702 • Fax: 254-771-1982

14

Order Form

BRAZOS STAMP & ENGRAVING, INC. (254) 774-7702

Fax: (254) 771-1982

Copy, Then Fax or Mail Your Orders

www.brazosstamp.com

DATE : _________________ Bill To : _____________________________________________

Ship To:

Company Name : ____________________________________

Attn : __________________________________________

Phone Number : (

) _______________________________

Company : ______________________________________

Street Address : ______________________________________

Street Address : __________________________________

__________________________________________________________

_____________________________________________________

City : _______________________________________________

City : ___________________________________________

State : ______ Zip : ____________ P.O.No.:________________

State : ______________ Zip : _______________________

Payment Method ❏ Bill my account : Account No.______________________________ ❏ Bill my Credit Card: ❏ VISA ❏ MASTERCARD Card Holder Name : ____________________________________ Card No.: _______________________________________________ Signature (Required) : _____________________________________ Exp.Date (Required) : ______________________________________ Fill out the information below to complete your order:

Stamps: ❏ XL2 Pre-Inked Stamp



Rubber Stamp



PSI Self Inker



MaxStamp Self-Inker

Special Instructions



MaxStamp Self-Inking Dater

Model Name / No : __________________ Quantity : ___________ Ink Color : ❏ Black ❏ Red ❏ Blue ❏ Green ❏ 2-Color Dater

Signs & Seals: ❏ ❏ Desk Seal

Wall Sign

Frame: ❏Yes ❏ No

Frame: ❏Yes ❏ No



Nameplate Only



Nametag



Embossing Seal

Model Name / No : __________________ Quantity : ___________ Size : Height ________ x Length ________ Color: ___________ Ink Color : ❏ Black ❏ Red ❏ Blue ❏ Green ❏ 2-Color Dater Choose typestyle for Stamps, Signs & Seals here

(Choose one from each column) Sample fonts: Style: ❏ Arial ❏ Standard ❏ Times Roman ❏ Bold ❏ Futura ❏ Italic ❏ Park Avenue ❏ Outline (Arial & Futura only)

(COPY) PLEASE PRINT, TYPE OR STAMP A SAMPLE IMPRESSION

For Daters, show copy above and below the date.

LT-32436