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NOTE: Dealers and Companies please provide dealer or company name, and also the nameof theperson to whose attention the
shipment should be sent.
Customer Name Attention
Zip CodeStateCity
Daytime Telephone Number
Checkhereif your billing addressis different from the
shipping address shown above.
Check ormoney order enclosed payable to Helm Inc.
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 ofdelivery. 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
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P
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210
Consumer Information
０９／１２／１５ １３：４８：１５ ３１ＭＧＲ６００ ０２１９
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