Multi-Fit Adult Stabilizer Wheels Request Form

Name:

Address:

City/Town:

Province/State:

Country:

Postal/Zip Code:

E-mail Address:

Please send me set(s) of the

Adult Stabilizer Wheels at the cost

of $95.00CDN per set, plus shipping

for the total cost of $.

(Ontario residents please add 8% P.S.T.)

Exchange Rate

Choice Of Couriers

I accept Bank Wire Transfers, Western Union,

AlertPay, Money Bookers, PayStone, Canadian/U.S. Cashiers Check or International Money Order & Personal Checks. Please make payable to:

Brian Wieland.

I do not accept

U.S. Postal Money Orders

(PLEASE DO NOT SEND CASH)

Please print off and mail this form to:

Brian Wieland
6-3330 South Millway
Mississauga, Ontario
Canada. L5L 3H4

905-569-6268

Email: order_asw@bwieland.com

No Printer, no problem just send this

form as an e-mail attachment or send

a hand written request.

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