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                  $34.95 USD per unit                         Total
$
5.95
Send Money Orders & Cashiers
checks  & Cash is also accepted &
International Money Orders
payable to:
If you want an email confirmation that we have
received your payment?  Print your email here.
Galaxy A.
1800 Dutch LN
# 115
Jeffersonville, IN 47130