A(euketiti fylxuuesi Qa/uHe^ti 
Route £uflit .... KnojotUlle, ^euueMee 
AMOUNT ENCLOSED $. DATE... 
NAME... 
STREET OR R. F. D. NO. 
POST OFFICE...STATE. 
QUANTITY 
VARIETY 
PRICE 
- 
■----- 
. 
TOTAL 
