Send Order Form to: Tim West
Pipes/JH Lowe & Co.
List pipes by maker or description, then describe the problem for each pipe.
6. (More Pipes List on Back of sheet)
Special Requests List Here:
City: State: Zip:
Country: Ohio County:
Phone ( ) Fax # ( )
Ohio Residents add 7.5% Sales Tax Total $ (includes shipping costs)
Accepted Payments - Visa, MC, AX, DISC, Paypal, Check, Money Order.
Credit Card Type: Credit Card #: Signature: Exp. Date: /
Security Code for VISA MC DISC 3 #'s on back _ _ _ Security Code for AX 4 #'s front _ _ _ _
Credit Card Billing Address: (if different than above) write it in below. Yes / No
Street: Apt: P. O. Box: City: State: Zip: Country_______________
Check Amount: $ Check: # Check Date: / /
*Do not fill in Charge Card Box if sending by e-mail please phone in the number.
*VISA, MC, AM. X., DINERS & DISCOVER - call 614-761-3465 with chg. number.
**Shipping minimum $7.95, actual shipping charges due on packages above Minimum Shipping Weight.
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