| 724 Chemin des Anglais | Tel: | 1 450 477-4410 | | Mascouche (Québec) | Toll Free: | 1-800-563-6785 | | J7L 3R6 | Fax: | 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: ______________________________
| Item | Quantity | Size | Unit Price | Total 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. |