HELMET DESIGN ORDER FORM
Address: 837 Osage Trail, Jamestown, Ohio 45335, USA
Phone: (937) 675-3559      FAX: (937) 675-3551
RHughesjr@woh.rr.com
 PLEASE PRINT CLEARLY AND IN BLOCK LETTERS (INK ONLY)
Item Number
Description: Print Size & Name, Initials, or Nickname
Price
Qty
Total
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Stripping Fee

 (As described on web-site)
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Sales Tax (all but shipping)
 (Call to see what the tax % is for your area.)
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Shipping/Handling
 (As described on web-site)
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Total Cost:
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Payment / contact details:
Name:

Office Use Only:

Address:
(if mailing address different from residence - please indicate)

 

  
Contact Phone No.:
     (            )
         Email Address:                                       @                                       
         (for order queries / processing)

Customer Comments:

 CHECK   /   MONEY ORDER   /  VISA    /   MASTERCARD   /   AMERICAN EXPRESS;
payments payable to "Helmet Designs" (Please Circle One).
Card Number:
Expiration Date:
Signature:
Name on Credit Card: