MACHINEBRAIN.COM

T-SHIRT ORDER FORM
Fill Out Form, Print, and Mail with Payment
YOUR SHIPPING ADDRESS
Your Name
Street Address
City
State/Province
Zip Code/Postal Code
Country
Email Address

ORDER FORM
Description

Price
$US
Quantity
Item Total
Medium - Robot Skull T-Shirt, Black Shirt with White Logo on Front
$9
Large - Robot Skull T-Shirt, Black Shirt with White Logo on Front
$9
Extra Large - Robot Skull T-Shirt, Black Shirt with White Logo on Front
$9
Subtotal
California Residents Only, California sales tax 8.25%
Shipping & Handling: US/Canada $3 per shirt
International $6 per shirt
Total $US

Print This Form and Send with Payment to:
Impactco
444 Alegra Terrace
Milpitas, CA 95035 USA

Check or Money Order Payable to "IMPACTCO"