Name: 

Address:

Phone Number:

Email Address:

Number of Cap Light (s):   1   2   Enter number ordering

Form of payment:  Check   Money order

Cap Light price:  $17.00

Extra battery pack price:  $5.00

Shipping/Handling:  $1.50  (or we can deliver at a running event)

Total of order: 

Print order form and mail to...Polansky Enterprises

                                         3837 Byers Ave.

                                         Fort Worth, Texas 76107

For information call 817-738-7475