| E-mail Address: * |
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| Name |
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| Date |
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| Attention |
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| If other |
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| Daytime Phone Number |
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| Billing Address |
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| Return Shipping Address |
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| I am sending Briley |
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| Make and Model |
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| Serial # |
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| List any accessories included |
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| Please return gun case, original box, and shipping materials to me |
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| Which chokes would you like? |
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| Flush or Extended Chokes? |
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| Which constrictions would you like? |
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| Do you want to upgrade your chokes to black, spectrum or ported? |
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| Additional Intructions |
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| I am including |
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| CC Type |
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| Name on card |
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| Card # |
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| Card Expiration |
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| Additional Info./Instructions |
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| Where did you first hear about Briley MFG? |
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| |
| * Required |
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