Date:________
Name:_______________________________________________
Address:_____________________________________________
City / State / Zip:_______________________________________
Your phone or email:___________________________________
Quantity Kit Number Price each Total
______ _____ __________ __________
If address is in Virginia, add 5.0% VA Sales Tax (x.05) __________
Check shipping choice (add to total per kit):
Ground $9.00
2-day $18.00 __________
TOTAL __________
Please enclose a money order or bank check payable to John Palecki Structures.
Personal checks OK but expect up to a three week delay for clearing.
THANK YOU!
PRINT THIS PAGE, FILL IT OUT AND SEND IT TO:
John Palecki Structures
3339 Collingwood Street NE
Roanoke, VA 24012
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