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NOTE: Dealers and Companies pleaseprovide dealer orcompany name, and also the name of the person towhose attention the
shipment should be sent.
Customer Name Attention
Zip CodeStateCity
Daytime Telephone Number
Checkhere if your billing addressis different from the
shipping address shown above.
Check ormoney order enclosed payable toHelm Inc.
U.S. funds only. Do not send cash.
MasterCard
VISA
Discover
Date
These Publications cannot be returnedfor credit without receiving advanceauthorization within 14days 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
Account Number
Security Code
()
P.O. BOX 07280, DETROIT, MICHIGAN 48207
HELM
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236
Consumer Information
１０／１２／１３ １０：０６：３６ ３１ＭＦＮＡ００ ０２４５
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