M O U T H P I E C E / R I M O R D E R FORM (Snail-Mail)
(Please print, complete 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 & mark details with an "x":
MOUTHPIECE MODEL, silver plate____ or in Polished Brass___
MEGA WEIGHT, silver plate____ Polished brass___ CARTOUCHE ___
Mark if you need Alexander or German stem ____
RIM MODEL in silver plate_____ in Delrin? ____ Gold Plate__
* * * *
TOTAL, incl.S/H (and Paypal charge if applicable): $____