Clock Order Form                                             

Clocks Page         Home   

You can call in an order, or fax or mail this form to place an order.  If you have any questions or need help filling out the 

form, please call.


Phone:  605-665-2621


Address:      Countryside Mfg. Inc.

                    30793 435th Ave.

                    Yankton, SD   57078


Shipping Address:______________________________________________________



E-mail: ______________________________________________________________  

Daytime Phone: _______________________________

Payment Method:

Check_______ Money Order or Certified Check________ Credit Card________ 

Credit Card Type:  (Circle One)           VISA              MASTERCARD              DISCOVER

Number:___________________________________   Exp. Date______________

Security Code - The last 3 digits in or close to the signature strip on back of card ___________

Name on card:______________________________________

Billing address of credit card if different from above:_________________________________________________


*All information will remain confidential and will not be given or sold to any other companies.

Type of Clock:         Small Wall Clock__________   Large Wall Clock__________

Choose Style of Face: (Circle One)




Choose Type of Wood:





Choose Stain: (Circle One)



Early American: Medium golden stain

Natural Walnut - may have light streaks

Provincial: Medium slightly reddish stain


Fruitwood: Light

Cherry Stain on Walnut

Natural Oak - very light


Natural Cherry

Dark Cherry



Panel Design:

None: _______

Please write in design number

Wood:____________  Glass:_______________

Photo or Custom Design:

Please include description and/or name of file if emailing image



For Glass Panel:   White Toned____________    Gold Toned_____________

For logos, custom, and photo designs, please include any special instructions below:

Printed photographs are not damaged and will be returned with the order. The photograph should have good contrast and be in focus. The subject(s) should not be too close to the edges of the photo. Please state whether you want the whole picture used or what part you want to zoom in on. Keep in mind the size and shape of the glass before choosing your photo, some cropping will occur in order to fit the photo to the glass. If you have any questions about the usability of the photo, please contact us. You will be notified of any problems with the supplied photo before any work is started. We are not responsible for damage in shipping. We suggest you sandwich your photograph in cardboard before mailing. If the photo is irreplaceable, you will probably want to use a tracking number on it, or have it scanned and email it to us. 

Digital photographs can be e-mailed to or sent on disk. The higher the quality, the better the final result will be. If you are scanning in a photo, the minimum setting should be 300- 500 dpi if the picture is the same size or larger than the final etching. If the photograph is smaller than the final product, please use as large a dpi setting as possible and still be able to send it. The image can be saved as a grayscale. If e-mailing the image, it should be saved as a " jpeg" with minimum compression and/or maximum quality settings. Some programs refer to this as "Print" quality.  Do not use "e-mail" or "Web" settings as these will make the image very low in quality.  It can be saved in a "tif" format if sending on a CD or disk. If you have any questions, please call. Digital photos from movie cameras are often too compressed or at a low resolution and will not give good results. If we have any doubts about the photo you send you will be contacted before use it.

Extra editing on the photograph, such as removing the background or combining photos, can be done for an additional fee. Call or email for pricing.

Please include any special instructions below.


Chimes - 2 styles to Choose From


Plays the Westminster melody, with progressive melody on the  quarter hour and counts out the hours.


Plays either Westminster or Whittington melody on quarter hours, strikes out the hours.  Has volume control, shut-off,  and night silencer


No Chimes

For Large Wall Clocks Only: Circle 1 top and 1 bottom

Traditional Top

Colonial Top

Traditional Bottom

Colonial Bottom

Stained Glass Panel:

Design #:_____________    Stained Glass Color Combinations #:_______________


Special Instructions: Please include any text you would like etched, the font you want to use,

and where you want it placed.






You can choose a font from this list. If you prefer a different font, write it in and we'll see if we have it available.


Please fill in Item #, Description, & Quantity. Leave the Price blank if you want us to figure the cost.

Item # 





Chimes - Plays the Westminster melody, with progressive 

               melody on the  quarter hour and counts out the hours.

Chimes-  Plays Westminster or Whittington melody on 

               quarter hours, strikes out the hours. Has volume 

               control  & Shutoff


Merchandise TOTAL

Ground Shipping Charges will be added based on weight & distance

If you want a shipping price, please call or email us for a quote.

Back to Clocks Page