Order Form

Ship to:

Name: ____________________________________________________


Address: __________________________________________________

                __________________________________________________


Phone: ______________________ FAX: ________________________

Payment
$62.95  (plus $5 shipping and handling US)

Form of payment  o Check   or    or 

Card #   __________________________________________________


Expiration: ________________________________________________


Signature: _________________________________________________

To Order please print this form. Fill it out and either FAX or MAIL it to:

Jim & Cheryl Farrell
P.O. Box 96
Roseburg, OR 97470
FAX: (541) 672-3367

or email Jim & Cheryl Farrell at:
cfarrell57@gmail.com