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Strum-Tar Order Form

Mail To: Strum-Tar Instruments Inc.

4513 Brinker Driver

Virginia Beach, Virginia 23462

Make checks or money order payable to: C. T. Doddy.

Date:_______________

First Name:______________ Last Name:__________________

Address:___________________________________

City:________________State:______________

Zip:_______________________

Phone: ( )______-____________

E-mail Address:____________________@_________________________

Ordered Items

1. Model Number:__________ Unit Price:________ Qty:_____ Total Price:_________

2. Model Number:__________ Unit Price:________ Qty:_____ Total Price:_________

3. Model Number:__________ Unit Price:________ Qty:_____ Total Price:_________

4. Model Number:__________ Unit Price:________ Qty:_____ Total Price:_________

5. Model Number:__________ Unit Price:________ Qty:_____ Total Price:_________

Virginia Resident add 4.5% Tax_______

Shipping and Handling: $12.00

Total Amount:_________

Reference Order Number:___________(Use yymmdd birthday as Order Number: Example 111850)

Cut Here and Save as Order Record

Strum-Tar Instrument Inc. Phone 757-474-1630

Date:______________

Reference Order Number:_________(Use Order Number listed above)