1.  Type in your info, and print this form & mail with payment.
2.  Or print this form, then fill it out & mail with payment.
*Please Print Clearly*
Name or Company
Address           Street              Apt.
City
State or Province                                           Zip Code
Country
Quantity                  Shipping                  $33.99 USD per unit                         Total
$
$8.95
Please note: Not available for download
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checks  & Cash is also accepted &
International Money Orders
payable to:
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received your payment?  Print your email here.
Contact us
Galaxy A.
1800 Dutch LN
Lot  115
Jeffersonville, IN 47130