Will Kirkpatrick's Decoy Shop - ALC                       Tel: 1-978-562-7841
124 Forest Ave.                                           Fax: 1-978-562-5211
Hudson, MA 01749-2840
U.S.A.

SOLD TO:                                 SHIP TO: (If not the same)

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Name                                     Name

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Address                                  Address

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City, State, Zip                         City, State, Zip

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Phone Number

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                                                      SUB TOTAL |          |
                                                                |----------|
                                For MA orders, add 5% sales tax |          |
                                                                |----------|
                                            Shipping & Handling |  $11.00  |
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PAYMENT METHOD:                                           Total |          |
                                                                ------------
( ) Check Enclosed, Make check payable to "Will Kirkpatrick's Decoy Shop".

( ) MasterCard or Visa

    Card Number: ______________________________  Expiration Date: ___________

    Signature: ______________________________________________________________

SHIPPING INSTRUCTIONS:_______________________________________________________

GIFT MESSAGE:________________________________________________________________