MAIL ORDER FORM

Print this page (1) and mail to:          

LVBC                                                                                             

PO BOX 101326                                                                            

Denver, Colorado  80205                     

Date__________________                        

ITEM:_______________________________________

Item number:___________________                                

Description of item:______________________________________________________         

__________________________________________________________

BUYER'S NAME AND ADDRESS:

Name:_________________________________________________________________

Address:_______________________________________________________________

Address:_______________________________________________________________

City:___________________________State______________________Zip_________

Phone:_________________________                                                        

E-mail:_________________________

May we confirm this order by:  Phone   yes___no___  U.S. Mail   yes___no___   E-Mail   yes___no___

SPECIAL INSTRUCTIONS:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

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