PRINT THIS PAGE AND MAIL WITH YOUR CHECK TO:

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JACQUE VAN NORREN
624 24th Place SW
Vero Beach, FL  32962

                Name: ______________________________________________

                Address:  ____________________________________________

                City: _______________________ St _____  Zip _____________

                Quantity:    ___________  X    $30.00                                $ _________

                          SHIPPING AND HANDLING ($ 5.00 each):             $ _________ 

                                                                        TOTAL ENCLOSED:    $ _________

please allow 1-2 weeks for delivery

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