Customer Information (please print clearly)
Address:__________________________________________________________
City:_____________________________________________________________
State:___________________________________ ZIP Code:________________
Shipping address (if different from above)
Address:__________________________________________________________
City:_____________________________________________________________
State:___________________________________ ZIP Code:________________
| Number ordered:___________ | x $19.95 | $_______________ Subtotal |
| Add Shipping & Handling: | $3.00 each | $_______________ |
| $_______________ TOTAL |
Please make checks payable to Patria Publishing. Allow 2 weeks for shipping.
| Mail to: | Paul R. Hollrah 1205 E. 10th Street Sand Springs, OK 74063 |