Pinhole Glasses Order Form

PINHOLE GLASSES ORDER FORM
www.pinholeglasses.org

To order online, use the Shopping Cart.
To order by mail, print this form and send with your check to IMPA, 1054 Gravel Hill Road, Ligonier, PA 15658. Foreign checks must be in $US and have machine-readable routing numbers at the bottom. No checks of any kind can be accepted from Canada.

Model Name	Unit Price	Quantity	Total
			$
			$
			$
			$

Total (Shipping is free).	$
Send package insured? Add $3.	$
Net	$

Shipping Information.
Enter a telephone number and/or email address in case of a question about your order.

Name:*

Address 1:*

Address 2:

City:*

State (if used):*

Postal Code:*

Country:*

Email (will be kept private):*

Telephone (will be kept private):

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