Hardcopy Mail Information Form

Hardcopy Mail Information Form

Please print this, fill in information, and mail, a letter will follow to inform you when it will be ready.

Beach Rocker 6Ft.(____) Lay Back (____) Sit Up (_____) Custom Built

Beach Rocker 5Ft. (____) Lay Back (____) Sit Up (_____) Custom Built

Heavy Duty Beach Rocker 6Ft..(____) Lay Back (____) Sit Up (_____) Custom Built

Heavy Duty Beach Rocker 5Ft.(____) Lay Back (____) Sit Up (_____) Custom Built

Fabric Color Blue _______________Gray ________________Outdoor Exposure Yes: ______ No: _______

The above 6Ft. frame for 5' 8"to 6' 6"+ Depending on leg & nee ratio from hip.
The above 5Ft. frame for 4' 8"to 5' 6"+ Depending on leg & nee ratio from hip.

Standard Rocker 6Ft. (____) Lay Back (____) Sit Up (_____) Custom Built

Standard Rocker 5Ft. (____) Lay Back (____) Sit Up (_____) Custom Built

Heavy Duty Standard Rocker 6Ft..(____) Lay Back (____) Sit Up (_____) Custom Built

Heavy Duty Standard Rocker 5Ft.(____) Lay Back (____) Sit Up (_____) Custom Built

Fabric Color Blue _______________Gray ________________Outdoor Exposure Yes: ______ No: _______

Airline Fabric Liner on first come basis. Limited to in stock availability:
Check web site link for stock & fabric number, also place other numbers in case non-availability:

#1 ________________________#2_____________________#3__________________________

Costom cushion can be made if so desired: Yes: ______ No: _______

The above 6Ft. frame for 5' 8"to 6' 6"+ Depending on leg & nee ratio from hip.
The above 5Ft. frame for 4' 8"to 5' 6"+ Depending on leg & nee ratio from hip.

Shipping charge for UPS 10% for Standard and Beach. Platform Rocker is fob in CT. No boxes to date.

Extra Shipping charge for UPS Zone 3 to 8

Rocker ordered $____________

Airline Fabric Liner $____________

Costom cushion $____________

UPS Std. 10% $____________

Total $_______________ Paid By MasterCard (___) or Visa (___)

#___________--___________--____________--____________EXP Date:_______--_______

Purchase paid with Credit card above (___) Cash (____) Check or Money Order (________________)

Comments? Questions? If you would like us to quote special modifications please include your height, weight, Dimensions #1 & 2 and a description of the requested modifications.

Your height,____________Weight, _____________Dimensions #1________________#2________________

Name:___________________________________________________________

Address:_________________________________________________________

City:__________________________State:________Zip Code:_____________

You can contact me by phone by leaving your number and best time to call back to reverse the charges. Made Rite Rocker Inc. 44 Gorman St. Naugatuck, CT 06770-4515 U.S.A. (203) 723-5600 Follow MadeRiteChair.Org

E-mail: mrropt@maderitechair.com

Click Name to send E-mail Robert J. St. Germain Sr. To Create Jobs

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