Model No.
(Required)
Left arm pad
Right arm pad
Head and lower back support
Back support pad
Head support pad
Base pad
Base assembly (without pad)
Shoulder belt positioning clip
Instruction booklet
Check or money order enclosed
(payable to Graco Children's Products Inc.)
Charge to credit card
Visa
Account #
Expiration date
Signature
SHIP TO:
NAME:
ADDRESS:
CITY, STATE, ZIP CODE:
TELEPHONE (including Area Code):
E-MAIL ADDRESS:
MasterCard
37
Subtotal:
Shipping
& handling*: $5.00
Sales tax**:
Total:
* $15.00 outside the
continental U.S.
** CA 7.25%, IL 6.25%,
IN 5%, NY 8.25%,
OH 5.75%, PA 6%,
SC 5%
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