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NOTE: Dealers and Companies please provide dealer or companyname, andalso thename of the person to whose attention the
shipment should be sent.
Customer Name Attention
Zip CodeStateCity
Daytime Telephone Number
Checkhere if your billing address is different from the
shipping address shown above.
Check ormoney order enclosed payableto HelmInc.
U.S. funds only. Do not send cash.
MasterCard
VISA
Discover
Account Number
Date
These Publications cannot be returned for credit without receiving advance authorization within 14 days of delivery. For returns, a restocking fee may
be applied against the original order.
Expiration: Mo. Yr.
Customer Signature
Apartment NumberStreet address/P. O. BOX
Security Code
()
P.O. BOX 07280, DETROIT, MICHIGAN 48207
HELM
P
A
Y
M
E
N
T
S
H
I
P
T
O
218
Consumer Information
０９／１２／１４ １５：０９：１３ ３１ＭＧＦ６１０ ０２２７
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