SHOWER SHIELD ORDER FORM

Please fill out the information on this form and and then please print it when you are done to send in.

Shower Shield Order Form (ELRA Industries Inc.)

Today's Date:    (MM/DD/YY)
First Name:        Middle Initial: 
Last Name:       
Mailing Address: 
City:             State: Zip:
Country:         

Phone Number:    
Fax Number:      
Email Address:

**The following products are currently available**
7001 Youth Lower Arm	7011 Youth Full Arm	7021 Youth Lower Leg	7031 Youth Full Leg	All Youth Sizes are $15.00 + Freight
7003 Adult Lower Arm	7013 Adult Full Arm	7023 Adult Lower Leg	7033 Adult Full Leg	All Adult Sizes are $20.00 + Freight

Freight Cost is $ 4.95 for one item - Plus $ 1.00 for each additional item.

Please enter the quantity, type, and price of the products you wish to order:

 Qty.      Item Description         Price

Please Add In The Freight Cost

Please place the total of your order here $. Please send a money order for this amount made out to ELRA Industries Inc, along with this form to:
ELRA Industries Inc. 550 South Erie Highway Hamilton, Ohio 45011-4346 U.S.A. How would you like us to confirm your order? Telphone Email Fax Do Not Need To Confirm
Thank you for your order!