Your Custom Cobbler  Mark J. Nelson, B.S., D.P.M.   Tel. 845-471-4158
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- Women’s…$ 12.75, Men’s… $17.99
 Package #2- replace heels, apply protective non-skid sole savers, reattach insoles, spot dye
                     scuffed stems and tips, shine- Women’s…$24.95 , Men’s… $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 - Women’s… $34.95 , Men’s… $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
Package #7- If none of the above choices meets your needs, please write a note on the back of this form 
                          detailing your requirements. Don’t 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 
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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