The Braille Game Board®
Printable Order Form
Company / Institution / State agency :__________________________________
Name: _________________________ First name: ________________________
Address: _________________________________________________________
City : _________________________Province / State: ______________________
Country : ____________________Postal / Zip code: ______________________
Phone : ( ___ ) ____________ Fax : ( ___ ) _____________E-Mail : ___________@_____________
Number of Braille Game Board® ordered: _______
A Certified cheque or a mandate is included in the amount of: ______
This is my Purchase Order Number : ________________
(All Purchase Orders are payable in 30 days)
I will pay "On Delivery"
(COD) :
Authorized Signature : _____________________________
Title :_________________________________
Rudbecom
Inc.
P.O. Box 67014 Lemoyne
St-Lambert, Quebec, Canada
J4R 2T8
To shorten delivery time and confirm your order, fax this completed form to: