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
$2.00	$0.01 - $9.99
$4.00	$10.00 - $24.99
$6.00	$25.00 - $49.99
$8.00	$50.00 - $74.99
$10.00	$75.00 - $149.99
$12.00	$150.00+

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!