NEW MINERALS ONLY FOR THIS FORM

Date

 _____________________________
PLEASE PRINT THIS FORM,
COMPLETE YOUR ORDER
AND MAIL TO:		    Roger's Minerals
    3171 Romeo Street
    Val Caron, ON Canada
    P3N 1G5		    Additional Info:
    rmineral@isys.ca
    Tel: 1-705-897-6216

SEND
ORDER
TO:
Name:  _____________________________________________________
Street Address:  _____________________________________________________
City & Prov./State & Country _____________________________________________________
Postal/Zip Code:  _____________________________________________________
email  _____________________________

FROM NEW
MINERAL LIST		LOCALITYSIZEQUANTITY$ AMT EATOTAL














































































*** Please ensure the above order is from the "New Additions" list. ***

SUB TOTAL

 
TOTAL $ SENT

SHIPPING

 
TOTAL ORDER

ONT. RES. ADD 8% PST

 
REFUND

TOTAL

 
REFUND SHIPPING CHARGES  YES  NO

CREDIT SHIPPING ON NEXT ORDER  YES  NO