bdorder

Last Name:____________________________________	First Name:_________________________	Middle Initial:________
Address:______________________________________	__________________________________	___________________
City:________________________________________	State:______________________________	Zip:________________
Home Phone:__________________________________	Work Phone:________________________
E Mail:_______________________________________	Fax:________________________________

QTY	DESCRIPTION/COLOR/SIZE	COST EACH	TOTAL
______	_______________________________________________________________________	___________	___________
______	_______________________________________________________________________	___________	___________
______	_______________________________________________________________________	___________	___________
		Subtotal	$___________
		CA Sales Tax 8.25%	$___________
	Postage will vary upon service and location, Contact us for information	SHIPPING	$__________
		TOTAL	$__________

Last Name:_____________________________________	First Name:_________________________	Middle Initial:________
Address:________________________________________	___________________________________	___________________
City:___________________________________________	State:______________________________	Zip:________________
Home Phone:____________________________________	Work Phone:_________________________
E Mail:_________________________________________	Fax:________________________________

Check type of payment: VISA___ Mastercard ___ Money Order ____ Check ____ Cash ____

Card Number:_________________________________________________________________

Expiration Date:_______________________________________________________________

Name on Card:________________________________________________________________

Authorized Signature:___________________________________________________
I am of legal age and authorized signer on this account (Sign Here)

To order please print out this form, fill out all the information , and return it by Fax or mail it with your payment payable to. Jungle Inc., 12896 Bradley Ave., Unit D, Sylmar, CA 91342 Phone , Fax, or E mail Your Orders.When Using Charge Card. Fax:(818)364-8241 Phone:(818)364-8242 E mail: bumperdmpr@aol.com (Orders paid by check are held until cleared)