P & S GUNS and MILITARIA Order Form

Tel: (819) 569-6880

Email: jeanplam@sympatico.ca

Date: ______________________

First Name: ____________________ Last Name: ________________________

Company:_________________________________

Street #: _____ Street: _________________ Apt/Suite #: ____________

City: ____________________

State/Prov: _______ Postal/Zip: __________ Country: _____________

Phone: Home: ( ) ____ - __________ Work: ( ) ____ - __________

Email: ________________________________

[ For Firearms Orders, please include a photocopy of your Permit ]:

P.A.L. #: ______________________ Exp. _______

Birth Date (mm/dd/yy): __________ Place of Birth: __________________

[ For Restricted Firearms ] Purpose: Collector [ ] Target Shooting [ ]

Name of Club: _____________________________ Member #: ______________

[Qty] [Part #] [Description/Condition/Etc.]

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