Box Cars & One-Eyed Jacks 6516 - 68 Avenue NW Edmonton, Alberta, Canada, T6B 3M3 Phone: (780) 440 6284 Fax: (780) 440 1619 Toll Free: 1-866-DICE FUN Email: boxcars@planet.eon.net Website: www.boxcarsandoneeyedjacks.com

Order by Mail, Phone, Fax or Email

Date:____________________

Purchase Order # (if applicable)______________________

AUTHORIZED SIGNATURE/TITLE:_________________________________________

SHIP TO (please type or print clearly) School/Institution_______________________ Attention Name/Title____________________ Street________________________________ City______________State_______________ Country____________Postal Code________ Phone_______________Fax______________

BILL TO (please type or print clearly) School/Institution_______________________ Attention Name/Title____________________ Street________________________________ City______________State_______________ Country____________Postal Code________ Phone_______________Fax______________

____________________________________________________________________________

..Catalog#......Quantity.....................Description......................Price Each........TOTAL.....










Back ordered item(s) may be substituted with item(s) of equal or greater value.

Make checks payable: In U.S. Funds to: Box Cars and One-Eyed Jacks Please allow 2-4 weeks ALL ORDERS MUST INCLUDE A PHONE NUMBER

SHIPPING RATES Orders $ 00.00 - $ 60.00 add $7.00 Orders $ 60.01 - $125.00 add 17% Orders $125.01 - $300.00 add 14% Orders $301.01 - $649.99 add 12% Orders $650.00 and up will be sent UPS only. All duty & taxes are the responsibility of the receiver. You will be billed directly by the broker. All U.S. orders over $650.00 must have an F.E.I. Number or Social Security Number for "SHIP TO" customer.

Subtotal $_______.___ Sales Tax$_______.___ (if applicable)XXXXXXXX Shipping $_______.___ Handling $_______5.00 TOTAL $_______.___