Backup Order Form

Name:

Daytime Phone Number:

Mailing Address (not a P.O. Box):





City:                      Prov./State:

Country:                   P./Zip Code:

                                      Quantity  Price
BackUP(s): $US 159 or $CAD 169
   each includes one CO2 cartridge      _____   _____
extra CO2 cartridges:
   $US 12.50 or $CAD 12.50              _____   _____
shipping                                        $ 15
                                     subtotal: _____

Canadian residents add 6% GST                  _____

                                        Total: _____

[ ] MasterCard   [ ] Visa   [ ] cheque or money order
card number:
expiration date:
signature:
Thanks for your order !
Roll-Aid Safety Inc.
P.O. Box 72005, Vancouver, BC, Canada V6R 4P2
Ph: 604-224-4010 Fax: 604-224-4045