Print out this order form and fax to:(410) 221-1693 or mail to the address below BROOKS BARREL COMPANY, INC. 5228 Bucktown Road ~ P. O. Box 1056 Cambridge, MD 21613-1056 1-800-398-BROOKS (2766)
Date:___________________________	Daytime Phone#:____________________________
Name:__________________________	E-Mail Address:_____________________________
Bill to Address:____________________ ______________________________________ ______________________________________	Ship To (if different):__________________________ _________________________________________ ___________________________________________________

Quantity	Product Code	Description	Price	Total Cost
Orders Shipped within the state of Maryland add 6% sales tax.			Subtotal
			Total

METHOD OF PAYMENT..................MASTERCARD ___ .............. VISA ___   ............ Check/Money Order enclosed  ___
_______________________________ Credit Card Number	(Make checks payable to Brooks Barrel Co., Inc.)
PRICES SUBJECT TO CHANGE WITHOUT NOTICE PLEASE ALLOW 2-4 WEEKS FOR DELIVERY	_______________________________    CID Number* last 3-digits next to signature on back of card
_______________________________          Authorized Signature for Credit Card Orders	_______________________________    Expires