Effective 20 Jun 2023
Repeat Customers: Please check
changed address? **_____  changed email address? **______

old address: ____________________________________________
SAMPUBCO NEW ORDER (PAPER COPY) FORM - WILL RECORDS

Quality is LIMITED

For Scanned Images orders - please do not use this form - Use the form
specifically for Scanned Images Order.
Name (PLEASE PRINT):**_____________________________________________________

Email (REQUIRED!):**_______________________________________________________

Street/P.O. Box:**_________________________________________________________

City/State/ZipCode+4:**____________________________________________________
(out of USA - City, Province, Country, Postal Code)
Order (do NOT alter the information as listed onsite in any way):

Name of Person:     Residence:  County of Record:  State, County # Vol, Page #
Example: DOE, JOHN  Anyplace    Anycounty          XX-50-35-80

1._________________________________________________________________________

2._________________________________________________________________________

3._________________________________________________________________________

4._________________________________________________________________________

5._________________________________________________________________________

6._________________________________________________________________________

Cost:
Paper Copy PER RECORD- send by regular first class mail
Number of records: ________X USD $15.00 = ___________if by PayPal / credit/debit card
(if paying by credit/debit card, please email order and request credit card invoice.)
Email address is dsam52 at sampubco.com for sending this order as attachment and
for sending payment via PayPal.

Number of records: _______ X USD $20.00 = ___________if by check (slow mail)

MANDATORY INFORMATION TO KNOW:
*** after the name, over 20 pages long, cost $40.00 per record. They are 20+pages.
**** after the name, contact for price quote. They are 40+ pages long. (Recommend
ordering them in Scanned Images instead.)

Please do NOT staple or tape check to the order. DO NOT COMBINE WITH
ANY OTHER TYPE OF RECORD!

Make check out to:
SAMPUBCO

Mail to:
W DAVID SAMUELSEN
629 S HARMONY CT
Salt Lake City, UT 84102-3446

STOP! Please check and verify the accuracy of the information. Do NOT forget
to list "County of Record", which is listed at top of the index page the
indexed information is found on.