Your Custom Cobbler Mark J. Nelson, B.S., D.P.M. Tel. 845-471-4158
REPAIR ORDER FORM
Step One Please tell me your:
Name _______________________________________________________________________
Address: Street_____________________________________________ apartment #________
City_________________________ State_______________ Zip Code____________
Daytime Phone# Area Code (_____) _____ - _______ E-mail________________________
Step Two Use a separate order form for each pair of shoes. Please describe the color and style of the
shoes that go with this form (example- black pumps). Description:________________________
Step Three Choose a repair package (circle your choice)
Dress Footwear
Package #1- replace heels, reattach insoles, shine- Womens
$ 12.75, Mens
$17.99
Package #2- replace heels, apply protective non-skid sole savers, reattach insoles, spot dye
scuffed stems and tips, shine- Womens
$24.95 , Mens
$29.99
Package #3- Complete Recrafting- replace heels and soles to mid shank, repair welt, replace
corking, reattach loose linings and insoles, dye stems and tips, resew loose buckles
and straps, shine - Womens
$34.95 , Mens
$44.95
Boots-Western (cowboy), Work, Hiking; and Rockport styles
Package #4- replace heels, reattach insoles, ink edges, shine
. $19.99
Package #5- Complete Recrafting- repair welt, secure shank, and replace cork, replace full bottom
with heels and soles to mid shank or premium quality unit sole matching original design.
Reattach loose linings , insoles, buckles, and straps, spot dye scuffs, oil or shine
$49.95
Birkenstock Sandals
Package #6- Recraft and Resole
$34.95
Other
Package #7- If none of the above choices meets your needs, please write a note on the back of this form
detailing your requirements. Dont hesitate to attach a photo, color swatch, or a copy (not
the original) of your orthopedic prescription. An initial service charge of $20.00 is required.
I will evaluate your shoes and call or E-mail you with my suggestions as well as total charges,
and I will complete your order once full payment is received, or return your shoes to you if you
prefer.
Step Four Payment (combine multiple orders to a single payment)
Repair Package #____ Description_____________________________________ Amount $ ________
Shipping back to you via regular U.S. Mail / U.P.S. is included in above pricing.
Optional Return Shipping Services: Next Day 1st pair $18.00
Next Day each additional pair $4.00
TOTAL PAYMENT- by check or credit card authorization below
..........$ _______
Credit card authorization: I accept (please circle one) Visa, MasterCard, and American Express
Card #_____________________________, Exp Date__ __ / __ __, Billing zip code ________
Last 3 numbers of security code following your signature on the back of your card ___ ___ ___
Statement: I agree to payment of the above charges according to the terms of my cardholder agreement.
Signature______________________________________ Date_________
Please mail your shoes, completed order form, check or signed credit card authorization to:
Mark J. Nelson,Custom Cobbler
17 South Hamilton St.
Poughkeepsie, N.Y. 12601
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