10962 Ridge Rd.
Belle Fourche, SD  57717
    Orders: (605) 892-2292
Name:________________________________________________________________Date:___________________
Address:__________________________________________________________________Apt:________________
City:________________________________________________________State_____Zip:_____________________
Telephone:______________________________________________Fax:_________________________________
E-mail:______________________
Personal Check_______     Money Order_______    Visa________    Master Card __________

Credit Card# _______-________-_________-_________                          Exp. Date:______/_________

Signature:________________________________________________
 
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DESCRIPTION 
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SUBTOTAL                        
SHIPPING  
 4% Sales Tax SD Residents  
   
TOTAL