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REFERENCES 
PLEASE PRINT NAME AND ADDRESS PLAINLY 
Enclosed Find_„_Date_ 
-19- 
Send to_ 
Street_ 
_R. F. D._ 
Post Office 
County 
Express or Frt. 0ffice_ 
Send by_ 
State 
IF OLD CUSTOMER Please give approximated date of last order. 
IF NEW CUSTOMER Please fill in reference space. 
Checked by_ 
1st Shipment. 
it 
2nd_ 
44 
3rd_ 
44 
4th_ 
14 
5th 
No.. 
Correspondence on Order Blank cannot be answered promptly. Please use separate sheet for inquiries, etc. 
SUMMARY 
CHARGES 
DATE 
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To Mdse. 
Cash 
Please do not write in above spaces 
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[ 
NOTICE—Please list 
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