Name _________________________

Mailing Address _________________________

City______________St____Zip___________

Quantity	Size	Cost	Total
	Small	$12 each
	Medium	$12 each
	Large	$12 each
	X Large	$12 each
Shipping			$3.00
TOTAL

Please enclose Check or Money Order made out to: David Fogler

Mail to:

David Fogler

18134 Mount Olive Dr.

Dade City, FL 33523

Please Allow 2 weeks for delivery.