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         TEXAS BRANDING IRON COMPANY               Phone: 1-512-335-6531 

         1420 DEER LEDGE TRAIL                              

         CEDAR PARK TX, USA, 78613                        1-512-479-1406

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BILL TO Name:                                      Daytime Phone:(    )

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SHIP TO Name:                                      Daytime Phone:(    )

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  Clearly sketch your brand here.      

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|                                |       I hereby authorize a representative of

|                                |       the Texas Branding Iron Company to act     

|                                |       as my agent before the proper Texas

|                                |       State and County authorities to register

|                                |       a Cattle/Livestock brand:

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|                                |       Signature

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|                                |                                      Date

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|                                |       Name as it will appear on certificate

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Actual size of brand will be approximately 4"     MERCHANDISE TOTAL   | 

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                         Texas Residents add your Sales Tax @ 8.25%   |

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Payment by:  ___VISA  ___MC  ___Check  ___Money Order         TOTAL   |

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Card #_________________________________________  Expiration Date:_____/_____



Card Holder Signature:______________________________________________________ 

                         (Required for credit card authorizations to ship)