ELECTRONIC RAINBOW
6227 Coffman Rd. - INDIANAPOLIS IN 46268

Date:_________

Name:___________________________________

Company:________________________________

Address:________________________________

City:_________________State:___Zip:_____

Phone:__________________________________

Model No:_______________________________

Description:____________________________

Quantity:_____Price:______Total:________

Charge #________________________________

Exp date:____Sig:_______________________

Total amount of goods:__________________

Shipping Charge:________________________

Indiana res. add 5% Sales Tax:__________

TOTAL ENCLOSED:_________________________

We accept Master Card or Visa by phone. 
Check or money order by mail. 
NO COD ORDERS.
317-291-7262 - FAX 317-291-7269

Please add sufficient postage,
1st lb, $5 Canade $7
Additional lbs, add $1   
US FUNDS ONLY    thank you