MAIL TO :
High Street Shoe Repair
233 High St. NE
Salem, OR 97301

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Customer Information

NAME

SHIPPING ADDRESS

CITY STATE ZIP CODE PHONE

EMAIL

BILLING ADDRESS SAME DIFFERENT

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Repair Order

BRAND COLOR REPAIR COST

REPAIR

DR. MARTEN SOLES   Circle One (4014 / 1705) HAFLINGER / STEGMANN SOLES   Circle One (1030 / 1328) SAS SOLES Circle One (1030 / 1328) LIFT   – SIZE OF LIFT : COWBOY BOOT ZIPPERS

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