724 Chemin des AnglaisTel:1 450 477-4410
Mascouche (Québec)Toll Free:1-800-563-6785
J7L 3R6Fax:1 450 477-4400
Web:http://www.kamikaze.com

Date:___________________ Name:____________________________________________________

Address:___________________________________________________________________________

City:______________________________ Province:______________ Postal Code:_____________ 

Tel:_______________ Fax:______________ E-mail:_______________________________________

Mailing address (if different): ________________________________________________________

Club: ______________________________ Instructor: ______________________________

ItemQuantitySizeUnit PriceTotal Price
     
     
     
     
     
     
     
     
     
     

Payment by:

MasterCard: _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _Expiry Date (M/Y): ___ / ___
Visa: _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _Expiry Date (M/Y): ___ / ___
American Express: _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _Expiry Date (M/Y): ___ / ___

X _____________________________ 
Signature

P.S: We will calculate the taxes and shipping for you.