Ship to:
Name: ____________________________________________________


Address: __________________________________________________

                __________________________________________________
Phone: ______________________ FAX: ________________________
Payment $62.95 (plus $7 shipping and handling US)
Form of payment  o Check   or visa   or Master Card
Card # ______________________________________________________
Card Security Number __________________________________________
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