NAME:_______________________________________________________________

STREET ADDRESS:____________________________________________________

CITY, STATE, ZIP:______________________________________________________

PHONE:(______)_______________________________________________________

                                   DATE OF BIRTH:_______________

                    Driver's License: State:_________________

                    Driver's License # :_____________________

I am over 21 years of age and I hereby state that there are no Local, State, or Federal laws that prohibit me from purchasing and receiving the ammunition and/or components ordered.

All purchases will be shiped to the above address unless otherwise requested.

Please submit a photocopy of your identification with this form.

Date:____/_____/_____       Signature:____________________________________

This form can sent by fax, e-mail or mailed in before shipping your order.