Plamondon & St-Pierre Order Form

Tel: (819) 569-6880

Email: jeanplam@sympatico.ca

Date: ______________________

First Name: ____________________ Last Name: ________________________

Company:_________________________________

[ Home Address ]: 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.]

___ ________ ___________________________

____ ________ ___________________________

____ ________ ___________________________

____ ________ ___________________________

____ ________ ___________________________

____ ________ ___________________________

____ ________ ___________________________

____ ________ ___________________________