Name: ______________________________________________________ Date: ___/___/___
Address: ____________________________________________________________________
City: ________________________________ State: __________ Zip Code: ______________
E-Mail Address (in case we have questions about your order): ____________________________
Item #: ______ Item Name: ______________________ Quantity: ____ Price: $________ Total: $_________
Item #: ______ Item Name: ______________________ Quantity: ____ Price: $________ Total: $_________
Item #: ______ Item Name: ______________________ Quantity: ____ Price: $________ Total: $_________
Item #: ______ Item Name: ______________________ Quantity: ____ Price: $________ Total: $_________
Item #: ______ Item Name: ______________________ Quantity: ____ Price: $________ Total: $_________
Item #: ______ Item Name: ______________________ Quantity: ____ Price: $________ Total: $_________
Item #: ______ Item Name: ______________________ Quantity: ____ Price: $________ Total: $_________
Item #: ______ Item Name: ______________________ Quantity: ____ Price: $________ Total: $_________
Item #: ______ Item Name: ______________________ Quantity: ____ Price: $________ Total: $_________
Subtotal: $_________
Massachussetts residents please add 5% sales tax: $_________
For shipping & Handling in Continental USA:
Orders totaling $49.99 or less — $5
Orders totaling $50 to $99.99 — $3
Orders totaling $100 and over — $1 $_________
Total: $_________
U.S. Funds only please. At present we can only accept Money Orders and Cashier's Checks payable to: Jose Diaz
Print out this form, fill in, and mail to address at top of form. No COD's please