Mike Gianlorenzo

PO Box 285

Rehoboth, MA 02769  USA

Voice # 508-252-4340

                                              Fax # 774-565-0111                                              __________________________________________________

Shipping Address,

Name:____________________________________________

Address:__________________________________________

City:______________________________________________

State:____________________________   Zip:____________

Country:__________________________________________

Billing Address if different from Shipping address,

Name:____________________________________________

Address:__________________________________________

City:______________________________________________

State:____________________________   Zip:____________

Country:___________________________________________

Telephone #________________________________________

Fax #______________________________________________

Invoice # ________________

Purchased Items,

1. __________________________________________________

Total = $____.00 + $___.00 (Global Express) = $____.00 Delivered

I, x__________________________________________________

Agree to purchase the following item(s) from RCK using my Credit Card,

Type:____________ # ________-________-________-________

                                    Expiration Date _____/______                                     __________________________________________________

When filled out please email or fax to 774-565-0111.

Your item will ship when this completed document is received and Funds have been deposited to my account.

Regards,

Mike @RCK