Split Jazz Bass Order Form
Fill out this form, Print it out and Submit with your order (Feel free to make any notes necessary pertaining to your order)
Your Name:
Daytime street address:
Daytime street address (cont.):
City, State, Zip Code:	, , -
Daytime phone number: (*Required for FedEX)
Shipping Rates: (*We only charge for 1st pound)	US Orders = $12 / Overseas Orders = Call for Quote
Select how many you need?	N/A 1 2 3 4 5 $120.00/each
Total amount enclosed with this order?	$
Notes/Comments regarding your order:
Lindy Fralin Pickups, 2015 West Laburnum Ave. 2nd Floor, Richmond VA, 23227 Phone: 804-358-2699, Fax: 804-358-3431
Split Jazz Bass Order Form/th>