Original Mirrycle Mirror Parts Order Form

Original Mirrycle Mirror Replacement Parts Order Form
Your local dealer may carry parts for your Mirrycle Mirror. But if they don't...
To order, please print and fill out this form. Enclose a check in U.S. Dollars, or use your Visa or MasterCard.
Mail to: Mirrycle Corp., 6101 Ben Place, Boulder, CO 80301 or Fax us at 1-303-447-9273 or email us at info@mirrycle.com

Item Description	Cost	Quantity	Total
Mirror Holder with Mirror	$ 6.00	#	$
Mirror Arm	$ 4.00	#	$
Mirror Stem	$ 5.00	#	$
Hollow Bolt	$ 4.00	#	$
Allen Screw	$ 0.50	#	$
Allen Wrench	$ 0.50	#	$
Nut Wrench	$ 1.00	#	$
Special Brass Insert	$ 0.50	#	$
Barrel Nut	$ 0.50	#	$
Shipping and Handling:			3.00
Total:			$

Name:	Date:
Address:	Phone:

Visa/Mastercard #:	Expiration Date:
Signature:	Check #: