PO Box 123
Jamesville, NY 13078
www.gold-mountain.com

Mail Order Form (for check or money order only)

Print this page out on your printer; fill in and mail it in for fast service.

SOLD TO:

NAME:______________________________________________________________

STREET ADDRESS:__________________________________________________

CITY:___________________________ST:__________ZIP:____________________
E-Mail address (if any):

SHIP TO (If different than above):

NAME:______________________________________________________________

STREET ADDRESS:__________________________________________________

CITY:___________________________ST:_________ZIP:_____________________

LIST ITEMS UNDER THE FOLLOWING HEADINGS:

QUANTY------TITLE OR DISCRIPTION-------------------PRICE----------------TOTAL

.............................................................................................Total Amount of Order:_________

..............................................................................................Sales Tax (NYS only):_________

................................................................................................Postage & Handling:_________

................................................................................................................TOTAL:________

Postage and Handling Rates:

Shipping charge is $3.00 to anywhere in the U.S.A and Canada (unless otherwise stated). Please email us for shipping costs to other destinations.

1. This form is for paying by check or money order only. The Secure Server must be used for credit card orders.
2. If this does not display or print properly, you may hand write an order.