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MAIL ORDER FORM

Publication price ............................................................................. $32.00

Additional charges [postage, packing #3 jiffy bag,] ..................... + $3.00

Total cost ........................................................................................ $35.00

Please enclose a check or money order for___________ made payable to Lowell L. Koontz

mail to:



Lowell L. Koontz

10905 Virginia Forest Court

Glen Allen, Virginia 23060 - 6503



Please Print Name _______________________________________________

Address ________________________________________________________

___________________________________________ Zip Code_____________