fOrM

BANKRUPTCY ORDER FORM

Name:_______________________________
Address:_____________________________
____________________________________
City:________________________________
Provence/State/Region:_________________
Country:_____________________________
Postal Code/Zip:______________________
Phone (optional):______________________
Email (optional):______________________

Method of Payment:
cheque[_].......money order[_].......cash[_].......trade[_]

all prices in Canadian or US dollars
all prices include postage for North American orders
orders for outside of North America add $2 for postage

CODE RECORDING FORMAT PRICE

| _______________________ | $

| _ | $

| _ | $

| _ | $

| _ | $

| _______________________ | $

SUB-TOTAL $

POSTAGE $

TOTAL $

CODE	RECORDING	FORMAT	PRICE
\|	_____________________________________________	\|	$
\|	_____________________________________________	\|	$
\|	_____________________________________________	\|	$
\|	_____________________________________________	\|	$
\|	_____________________________________________	\|	$
\|	_____________________________________________	\|	$
		SUB-TOTAL	$
		POSTAGE	$
		TOTAL	$