Order Form

Please Print Information:

Name_____________________________________________________ ___ _________

Address________________________________________________ _______________

City_______________________________________State_____ Zip+4_____________

QUANTITY ----------------ITEM DESCRIPTION---------- ------TOTAL COST (US$)

______________ __________________________________ ____________________

______________ __________________________________ ____________________

______________ __________________________________ ____________________

______________ __________________________________ ____________________

______________ __________________________________ ____________________

Total for Ordered Items   $___________

Shipping                         $___________

Total Amount Due          $___________

Payment (Check or Money Order for Mail Orders) Amount (US$) ____________

Before sending in a Mail Order and Payment'please contact:    Michael J. Dietz


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This page was last updated on: February 14, 2017

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