Brockman's Mellowtone Order Form

                                                        940 S. Washington St.

                                                        Hagerstown, IN 47346

                                                    Phone & Fax # 765-489-4111

Please call or fax you order between the Hours of 9:00 am - 4:00 pm.

At this time, Please print order form and either mail or fax it to us. You may also email it to us, but the form will not be secure. Hopefully soon we will have the form setup to accept through email. You may also call your order in. Thank You!

Date:            

Name:          

Address:      

Phone:         

Automobile Information:   

Qty.              Description                                                                                                            Color            Price                Total

                                                                                                                                                                       Each                Price

                                                                                                                                                      Merchandise Total 

                                                                                                                                                                   Sales Tax  

                                                                                                            If prepaid add 15% of total for Shipping Costs 

                                                                                                       LakePipes & Skirts Add 20% (Excess Refunded) 

                                                                                                                                                            Shipping Total  

                                                                                                    Sales Tax                                                       Total  

                                                                                                    Indiana 7%, Wisconsin 5%             

                                                                                                    Ohio, Michigan 6%

                                                                                                    Illinois 6.25%

                                                                                                    Minnesota 6.5%

                        U.P.S.        C.O.D.                                              Card Holder Signature

                                                                                                             Card Holder Name (Please Print)

                                                          Card Number

                                                          Card Expires

                                                          Mo./Yr.  / 

Mail Orders Can Be Money Order, Cashier Check, Or Personal Check. Don't Send Cash.