Medina-Made Order Form

Strap Name: ________________________________________________________

Strap Ordering Number:______________________________________________

Do you need to pick a color? _______________________________________

Name: ______________________________________________________________

Street address: ____________________________________________________

City: _____________________________  State: ______ ZIP: ____________

Phone: ________________________  Email: ____________________________

Include money order or cashier's check only for the amount of the strap plus $5 shipping and handling for the first strap and $3 for each additional strap, and mail this form and payment to:

Julius Medina
2216 Stonesthrow Dr.
Lapeer, MI 48446

Thank you.