Name ______________________________________________________  Work Tel #____________________

Street Address  (Mail)_________________________________________  Home Tel#____________________

City ______________________________________________________  State __________  Zip ____________

E-mail_______________________ Item I am buying __________________________Price of item $__________

Shipping, Handling & Insurance $_________________Strings, Parts, Case, Etc. $__________________ 

Choose Method Of Payment
_____ Enclosed is (Certified Check) $____________ The balance if any is $__________________
          Ed Roman Ships instantly on Certified Checks,  
_____ I will mail you the balance by approximately this date_____/______/_____
_____ I would like to pay the balance COD 
_____ I will need Ed Roman to call me when it arrives to discuss balance.
_____ I am using a credit card, so I will also be sending you a Special Order
_____ I am Wire Transferring
_____ I don't have all the money now,  Please put this item on Layaway for me.

_____ My shipping address is written below.     (Only fill in If different from above)