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Please fill in your shipping address:

Name: ______________________________
Street: ______________________________
City: ______________________________
State / Province: ______________________________

Zip / Postal Code:

______________________________

Country:

______________________________
Phone No.: ______________________________
Email: ______________________________

Your order will be shipped when we receive and process your check or money order:

Quantity _____ Canada Order @ $ 20.00 CDN = Total _____

Quantity _____ USA or international order @ $ 20.00 USD = Total _____

Make out your check or money order to JOHN CHIASSON

Print out this page and print it along with your check and send it to

"Here In The Moonlight"
22 Major St.
Dartmouth N.S.
Canada B2X 1A4