Date______________________

Your Name________________________________________________________

Your Address (street, city, state, country)____________________________________

Shipping Address (if different from address above):
________________________________________________________________________________

Home Phone w/ Area Code (please note best time of day to call)_____________________

Work Phone w/Area Code (is it okay to call you at work?)__________________________

Home Fax__________________________  Work Fax_____________________________

E-mail Address (our preferred mode of communication)____________________________

Style of Stock Firescreen___________________________________________How many?_____

Are you wanting to install yourself?__________ Do you have help?___________   Will you have it installed professionally?________________________________________________

Can you think of anything that would interfere with the flush mounting of this firescreen? ___________________________________________________________________________

Any other info?_____________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Remember, YOU CANNOT GIVE US TOO MUCH INFORMATION!