I have reviewed the items and quantities for this order. I approve it for production and am authorized to do so. Approved by:

For each name enter only the number of pieces you would like to order. Please do not enter zeros, but leave them blank. There is no minimum per name (1's are allowed). Include PO# if applicable and have order signed by an approved buyer.

Instructions: Notes:

Date:Store:

Address:

Zip:City: State:

PO#: Rep:

Form: N-103

P.O. Box 221 Payson, UT 84651 USAPh: 800-292-6079 Fax: 800-291-6079orders@gowesternstar.com

MZP“SHINERZ”

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