[Company Logo Image]

143 Doty Cir.
West Springfield
MA 01089   USA
tel. (413) 732-3899

Parcel Shipment Order

Parcel Type (check one):

     | Sea (to Poland)     | Air (to Poland)     | Sea (to other countries)
Sender
Name:  
Address:  
Zip, City:  
Recipient
Name:  
Address  
Zip, City:  

Parcel  Contents

Description Qty/Amt Description Qty/Amt
       
       
       
       
       
       
       
Contents Value for Customs: $
  
Parcel Weight (lbs)
  
Price/lb $
  
Shipping Price $
  
Additional Insurance (YES / NO)
  
Service Fee $
  
Amount Parcel Insured for $
  
Insurance Amount $
  

 
Total Amount Due $
  
I hereby acknowledge and accept all pertaining shipping regulations and declared parcel contents


Signature

Please print clearly in places indicated.
Please check Parcel Shipping price list for Shipping and Insurance fees or Additional Insurance.
Attach personal check or Money Order and mail directly to POLONEZ PARCEL SERVICE

To print this form click on "File" and "Print" from your browser menu
or press <Ctrl> and <P> buttons simultaneously or...