QUANTITY

_________ Special National Farmers Income Tax Record

_________ Small Business Income Tax Record

PREPAY ON 25 BOOKS OR MORE AND GET FREE FREIGHT

_____ CHECK FOR __________ ENCLOSED

Charge to My ____ Visa ____ MasterCard ____ Discover ____ American Express

Card # __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ (__ __ __ )

Expiration Date _____________

Use Same Imprint As Last Year _____ Do Not Imprint ________

Use the Following Imprint: ___________________________________________________________________________________________

Ink Color: Standard Black ___________________________________

Name ____________________________________________________

UPS Shipping Address ______________________________________________________

City ____________________ State___________ Zip ____________________

Phone __________________________ Signed ____________________________

Mail to: McLeod’s Printing & Office Supply Fax to: 1-605-996-1488

Post Office Box 699

Mitchell, SD 57301