| Rhino Riders Patches |
| No. of Rhino Rider main patches : ________ X $8.00 = $ _________ No. of ' Plate # ' rockers: ________ X $3.00 = $ _________ TOTAL PAYMENT = $ __________ 1st rocker Plate No.: ___________ 2nd rocker Plate No.: ___________ 3rd rocker Plate No.: ___________ |
| Name: _________________________________ Phone: ________________________ Address: ________________________________ Email: _________________________ City: ___________________________ State: ________ Zip: ____________________ |
| Mail with payment to: Piper's Enterprises 575 County Rd. 159 Westcliffe, CO 81252 |
| For direct Visa or MasterCard payment ($10 minimum), please contact us for information Sales@PipersEnterprises.com 913-904-0074 |
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| To mail in payment, print off this form and mail in with information completed |