Tom Lillo Order Form

Name:  __________________________________________________________  Mailing Address:  __________________________________________________________  City:  __________________________________________________________  State:  __________________________________________________________  Zip:  __________________________________________________________  Home Phone:  __________________________________________________________  Work Phone:  __________________________________________________________     Check one: Check Money Order  Quantity  Title  Price  Subtotal  _______  BLUE EYED MYSTIC (1 CD)  $15.00 ea.  $___________          _______  Shipping INSIDE the continental U.S.  $2.00 ea.  $___________  _______  Shipping OUTSIDE the continental U.S.  $5.00 ea.  $___________              Total:  $___________ Send your check or money order to: Tom Lillo Insurrection Records PO Box 2573 Malibu, CA 90265