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