Checks Payable to: Doctor Don's

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Ship To: Doctor Don's                                                     Phone (936) 435-1811

               225 FM 247

               Huntsville, Texas 77320

Fill out the Shipping/Payment Form to include with Your Radio or Electronic Component

Please provide a Street Delivery Address

  Date:____________                          Model#________________                Serial#_________________

Method of Payment (Check One):            ___ Cashier's Check or Money Order              

                        ___ Personal Check           ___ Cash

Please Provide a Day Time Phone # (        )_____________________________

Ship To Address ( please complete if paying with Check/MO or different than above)

Name_______________________________________________

Address_____________________________________________

City_________________________                  State__________________               Zip Code__________

Phone # (        )_____________________________