back                           Middlepeg Order Form

Please print the following form.  
For prompt and efficient delivery please ensure all details are correct.
Fax it to us at:  (08) 9410 2491 (local) or +61 8 9410 2491 (international) or
Mail it to us at:   Middlepeg Orders
                         PO Box 1010
                         Bibra Lake   6965
                         Western Australia

Customer Name _____________________________________       Date _____________

Delivery Address _________________________________________________________

 _____________________________________________     Postcode/ZIP _____________

Home Phone ______________  Work Phone _____________  Mobile _______________

Fax _______________                Email ________________________________________


Middlepeg
 Code

                        Item & Description
 (Include colour, size, right/left handed - if applicable)

 Quantity     Price
 (per unit)
   Total    
         
         
         
         
         
         
         
         
                                                                                                    * Plus Postage +  ________
                                                                                                             
                                                                                                 TOTAL (AUS $) =  ________
Payment Details

  Cheque**    Money Order      Visa Card       Mastercard       Bankcard

Credit Card Number     __ __ __ __    __ __ __ __    __ __ __ __    __ __ __ __

Cardholders Name (as shown on card) _________________________________________

Expiry Date _____________           Cardholders Signature ________________________

  *  Overseas orders please contact us for the most suitable postage option.
**  Orders by cheque will be dispatched after cheque has cleared.