| First Name | |
| Last Name | |
| Street Address | |
| Address (cont.) | |
| City | |
| State | |
| Zip/Postal Code | |
| Home Phone | |
| Preferred Contact Method |
Minimum order of 50 pc per color for custom colors
| Lure Style | |
| Base Color #1 | |
| Base Color #2 | |
| Glitter color in base #1 | |
| Glitter color in base #2 | |
| Highlight color for base #1 | Highlight color for base #2 |
| Qty | |
| Special Instructions |
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