M O U T H P I E C E / R I M  O R D E R  FORM  (Snail-Mail)

(Please print, fill in and mail to: Moosewood, 9327 W. Briarwood Circle, Sun City, AZ 85351)

NAME_____________________________________________  DATE:_______________

ADDRESS__________________________________________

CITY______________________________________________

STATE/PROVINCE__________________________________ ZIP/Code_______________

COUNTRY_________________________________________

TELEPHONE  ________________________________

E-MAIL_____________________________________

(Note: Private Info is NEVER given out.)     

Fill in Model number or mark details with an "x":                                                                  

MOUTHPIECE MODEL in Silver plate:______   "x" here for Polished Brass:___

MEGA WEIGHT in silver plate:______    "x" for Polished brass:___  CARTOUCHE? ___

Check here if you need Alexander or German stem:____

RIM MODEL _____in Silver plate. Delrin? ____ Gold Plate?__ 

* * * *

TOTAL, incl.S/H (and Paypal charge if applicable): $____