Jewels by Park Lane JEWELRY SAMPLE ORDER FORM

Jewels by Park LaneJEWELRY SAMPLE ORDER FORMDATENAMETITLEADDRESSCITY STATE ZIP CODETELEPHONE NUMBER ( )SOCIAL SECURITY NUMBERPark Lane representatives have the option of purchasing one sample of any regular in-line item at a 60% discount,one sample of any Three Booking Gift for $20.00, one sample each of any “Hostess Only” items for the discountedhostess price listed in the catalog. ONLY ONE of each item may be purchased. No duplicates of the same itemmay be ordered. To order sample jewelry items, list your selections in the applicable category.(If additional space is necessary, use a second form.)CATEGORY #1 - REGULAR IN-LINE JEWELRYITEMNUMBERITEM NAME(Please indicate size, length, and color choices as well as pierced or clip preference if applicable.)RETAILPRICE60%DISCOUNTYOURSAMPLECOSTREGULAR IN-LINE JEWELRY SAMPLE TOTAL$CATEGORY #2 - THREE BOOKING GIFT ITEMS - $20.00 eachITEMNUMBERITEM NAME(Please indicate ring size if applicable.)YOURSAMPLECOSTTHREE BOOKING GIFTS SAMPLE TOTAL$

CATEGORY #3 - “HOSTESS ONLY” ITEMSITEMNUMBERITEM NAME(Please indicate size, length, and color choices as well as pierced or clip preference if applicable.)LISTEDHOSTESS PRICE(already discounted)“HOSTESS ONLY” ITEMS SAMPLE TOTAL$CATEGORY #1 - TOTAL REGULAR IN-LINE JEWELRY SAMPLE ITEMS $CATEGORY #2 - TOTAL THREE BOOKING GIFT SAMPLE ITEMS $CATEGORY #3 - TOTAL “HOSTESS ONLY” SAMPLE ITEMS $Guarantee: Any kit item, sample item, or promotional item that is foundto be defective may be returned to the Home Office within the first 30days. No fee is required for returning an item during this period. After thefirst 30 days, there is a $5.00 service charge for the replacement of wornor damaged in-line jewelry items.($12.00 service charge for watches.)SUBTOTAL $PLUS_____% SALES TAX $PLUS INS. & TRANS. $ 5.50GRAND TOTAL $Discontinued items may not be returned in exchange for current items. Replacements of SAME ITEMS ONLY are allowed. No alternatechoices will be permitted.Please enclose cashier's check or money order or when opting to utilize Visa / Master Card / Discover Card, complete the following information: Cashier's check or money order attached Charge to my (circle one) Visa Master Card Discover CardComplete an original and make a copy. Keep a copy for your records andsubmit the original copy to the Home Office. The copy will be returned asyour validated guarantee.Send to:Park Lane100 East Commerce DriveSchaumburg, Illinois 60173THIS SECTION FOR CHARGES ONLY VISA MASTERCARD DISCOVER AMEXAUTHORIZATION NO.TOTAL AMOUNT CHARGEDEXP. DATECARDNO.CARDHOLDER'S INFORMATION (Must be completely filled in and signed to process credit card)NAME (print) TEL. ( )BILLING ADDRESS ZIP CODECARDHOLDER'S SIGNATURECID#Printed in the U.S.A. SMPLORDR (rev. 5/06) ITEM #007