Phonographs.org Order Form

Send this form along with
check or money order to:

John Nagy
Antique Phonograph Repairs
8160 New Liberty Road
Walcott, IA 52773-9741
USA

	Please Print Clearly.
Name:	___________________________________________
Address:	___________________________________________
City:	___________________________________________
State:	___________________________________________
Postal Code:	___________________________________________
Country:	___________________________________________
Email:	___________________________________________
FEIN:	__________________________ (Tax ID # for dealers)

All funds are in US Dollars (USD).

Quantity

Item Code

Cost Each

Line Total

Example:

2

N-108

9.95

19.90

Item #1

Item #2

Item #3

Item #4

Item #5

Shipping Charges
Shipping Rate	Item Subtotal
$2.50	$0.01 - $14.99
$4.50	$15.00 - $29.99
$6.50	$30.00 - $49.99
$8.50	$50.00 - $69.99
Free to Continental U.S.	$70.00+

Sub-Total:*

Tax (7%):
(IA residents only)

*Shipping:
(based on Sub-Total)

Grand Total:

You will be contacted by email regarding the shipment of this order.

Thank You!