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(CUSTOMER’S NAME)


(ATTENTION)


(STREET ADDRESS—NO P.O. BOX NUMBERS)


(CITY)


(STATE)


DAYTIME TELEPHONE NO.


( )


AREA CODE


(ZIP CODE)


Check or Money Order payable to Helm, Inc. (USA funds only — do not send cash.)


MasterCard


VISA


Discover


Account Number: Expiration Date mo/yr:


CUSTOMER SIGNATURE


TOTAL MATERIAL


Michigan Purchasers add 6% sales tax


U.S. Order Processing


Canadian Postage (See Note Below)


GRAND TOTAL


$6.00


Check here if your billing address is different from your shipping address shown.


GM-OLD-ORD99


*(Prices are subject to change without notice and without incurring obligation. Allow ample time for delivery.)


Note to Canadian Customers: All listed prices are quoted in U.S. funds. Canadian residents 8-13
are to make checks payable in U.S. funds. To cover Canadian postage, add $11.50 plus the U.S. order processing.


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