Address________________________________________________ _______________

City_______________________________________State_____ Zip+4_____________

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

______________ __________________________________ ____________________

______________ __________________________________ ____________________

______________ __________________________________ ____________________

______________ __________________________________ ____________________

______________ __________________________________ ____________________

Total for Ordered Items   $___________

Shipping            &nb sp;           & nbsp; $___________

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: April 17, 2010.