SAMPLER RECORDS LTD. • PO BOX 19270 • ROCHESTER NY 14619

phone 585-464-9377• fax: 585-328-2010 • e-mail: SamplerRec@aol.com

* SALES TAX is due only on shipments to a New York State address. Please calculate appropriate tax on the Sub-total amount.

* SHIPPING AND HANDLING CHARGE is $5.50 on orders of $50 or less.

* SHIPPING AND HANDLING CHARGE is $8.00 on orders of more than $50.

Merchandise Cost

Discount

Discounted Cost

Shipping

Sub-total

Sales Tax *

Total Payment

Name

Address

City / State / ZIP

E - mail