ORDER FORM:         

ROCKY MOUNTAIN ARMS, INC.
1813 Sunset Place, Unit D
Longmont, Colorado   80501
(800) 375-0846    (303) 678-8522    Fax (303) 678-8766


Date:    ___________________

Customer Name: ___________________________________________

Street Address: _____________________________________________

City: _____________________________ State: ___________________

Zip Code: ________________________ E-Mail Address ___________________________________

Daytime Phone:    Area Code _________ Phone:_______________


Firearm Manufacturer: _____________________________________  Serial#________________________

Caliber:_________________   Model: __________________________ ( ) form-4 copy attached

Finish Desired :  (  ) FBI flat black  (  ) Matte Black  (  ) Gloss black ( ) Desert tan

(  ) Navy Gray  ( ) Dark Gray   (  ) Green    (  ) add black tiger stripes  

(  ) Rings & Bases  (  ) Muzzle Brake (  ) Extra Mags ____________
                                                                            ( 2 free w/gun) 

Special Instructions:________________________________________________________________________    

Return shipment via ( ) Cheapest way  ( ) Ground  ( ) Air ( ) next day  ( ) 2nd day                                                                                                              _

                    ( ) insurance requested $ _________________________                                                                                                    _  

Payment Type: (  ) Money Order/Cashiers Check Enclosed
(  ) Visa   (  ) MasterCard  (  ) Discover  (  ) American Express

Card Number: __________________________________________________ Exp.:_______________

Name on card:_______________________________________________

Signature: ___________________________________________________