Order Form

Customer Order Form

Once your order is submitted we will contact you to confirm your order and also get your payment information. We accept Mastercard, Visa and Discover.

First Name:
Last Name:
Address Street 1:
City:
Zip Code:	(5 digits)
State:
Daytime Phone:
Evening Phone:
Email:
Fireplace Length:
Fireplace Depth: (up to 12" included in price)
Color Selection:
Does your Jack-Mat need Sides?	Left SideRight SideBoth
Comments:	Enter comments here!

Prices Based Upon a 12" Depth

Up to 5'     $216.95
5'1" - 5'11"       $258.95
6' - 6'11"           $294.00
7' - 8'1"         $334.25

Please Add 40% for depths over 12"
Shipping will be via UPS or FedEx
Hand Delivery in St. Louis $25.00
Missouri Residents Add 6.725% Sales Tax