rForm No. GOOV 



JnHt ©ffirp Sppartmrnt 



THIRD ASSISTANT POSTMASTER GENERAL 

 DIVISION OF MONEY ORDERS 



No. 



Stamp of Issuing Office 



DOLLARS ' CENTS | 



Ti:^ Postmaster 

 wnS insert 



here^ 



th5 ttffice drawn on, when the oflBce named by the 



reffif&er in the body of this application is not a Money Order Office. 



Spaces above this iioe are for the Postmaster's record, to be filled in by him. 



/if plication for Domestic Money Order 



Amount 



P£»^io 

 Ond«- of 



Spaces below to be filled in by purchaser, or. if necessary, 

 by another person for him. 



Dollars Cents 



WM. HENRY MAULE, INC., 



'Name of person or firm for whom order is intended. 



AcMbess - 



Po^ti 



Of 



PHILADELPHIA, 



.Street 



5^ Pennsylvania. 



Seetby. 



(Name of Sender) 



Addre^ ) 

 of [ 



sender ) No Street 



PURCHASER MUST SEND ORDER AND COUPON TO PAYEE 



