Graff's Shoe Service
13710 Olive Blvd.
Chesterfield, MO 63017
Phone/Fax: (314) 434-9630

REPAIR ORDER FORM

Please fill out form completely then print by selecting your browser's print button. 
Send form and payment along with shoes to be repaired to the address above.

Please provide the following contact information:

BILLING INFORMATION
First Name:  Last Name:
Address:  Address (cont.):
City:  State: Zip Code:
Daytime Phone:  E-mail: 

Select Method of Payment:

Personal or Cashier's Check   Money Order    Credit Card
(Please make check or money order payable to "Graff's Shoe Service". If paying by credit card, fill out the information below.)

Card Type:
Cardholder Name:  Card Number:
Expiration:
Signature:
(order will not be processed without signature of card holder)
_____________________________________
SHIPPING INFORMATION
Check if Same: 

  Same as Billing Information
Street Address:  Address (cont.): 
City:  State:  Zip Code: 

Please indicate quantity and type of repairs to be made:

REPAIR INFORMATION
# of Pairs Repair Type Sole Type Heel Type Price Ea. Pair Total Price

Please Pay This Amount:

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