M & R Specialties
1126 S. Gratiot Ave.
Mt. Clemens, MI 48043
(586) 954-3998
Date: ___________________
Customer Name: ___________________________________________
Street Address: _____________________________________________
City: _____________________________
State: ___________________
Zip Code: ____________________
E-Mail Address ___________________________________
Daytime Phone: Area Code _________ Phone:_______________
Firearm Manufacturer: _____________________________________
Serial#________________________
Caliber:_________________ Model: __________________________
Finish Desired :________________________________________________
( ) Rings & Bases ( ) Muzzle Brake ( ) Extra
Mags ____________
Special Instructions:____________________________________
Payment Policy: We accept only money orders, personal checks, or cashier's checks for work provided. Shipping costs are determined when work is completed and may be paid by credit card (Visa or Master Card), money order, personal check, or cashier's check.)
Payment Type: ( ) Money Order ( ) Cashier's Check ( ) Personal Check
Card Number: ___________________________ Exp.:_______________
Name on card:_______________________________________________
Signature: ___________________________________________________ |
