Phonographs.org 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
$3.00 $0.01 - $14.99
$5.00 $15.00 - $29.99
$7.00 $30.00 - $59.99
$9.00 $60.00 - $79.99
$11.00 $80.00 and up
Shipping for larger/heavier items will be arranged separately.
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!