Postal Order Form

Adapter Plate
To place a postal order print this page and fill in the blanks
Please Print Clearly.
Ship To:
Name :	_________________________________Call________
Address :	____________________________________________
City :	____________________________________________
State :	___________________ Zip Code : ________________
Email Address :	____________________________________________
Phone Number :	Optional _______________________

Please send Check Or Money Order for $18.00 ( $15.00 + $3.00 S+H ) for each Adaptor Plate To :

	Raymond Berry
	2095 Stortz Ave N.E.
	Salem , Oregon 97303

	Personal checks please allow 10 days to clear the bank