Name:

__________________________________

Callsign:

___________

 

Street:

___________________________________

Apt or Suite:

_______

 

City:

___________________

State/ Province

:

__________

Country:

_________

 

ZIP/Postal Code:

_______________

Phone Number:

________________

Antenna	Cost (ea)	Quantity	Shipping (ea)	Total
6M	$120	______	$30	________
2M	$60	______	$10	________
135cM	$60	______	$10	________
70cM	$60	______	$10	________
Phasing Harness(es)- Circle Band(s):	$50	______	$10	________
6M      2M    135cM   (Not available for 70cM) Quantity of each:		Shipping (Contact Norm if ordering multiple items)		________
____   ____   ____			Total Order	________

Method of Payment -

Check applicable blank and fill in applicable data:

Check

___

Postal Money Order

___

___

___

Card No.:   ____________________________________

Expires:

_______

Signature:   ___________________________________		Date:   _________

Norman W. Pedersen, KB6KQ PO Box 430 Kalama, WA  98625 Phone/FAX: 360-423-4905

For Office Use Only
	Authorization:   _______________		Shipping Date:   _________