Model No.
(Required)
Left arm pad
Right arm pad
Head and lower back support
Back support pad
Head support pad
Base pad
Base assembly (without pad)
Shoulder belt positioning clip
Instruction booklet
Subtotal:
Shipping
&handling*: $5.00 Sales tax**:
Total:
*$15.00 outside the continental U.S.
**CA 7.25%, IL 6.25%,
IN 5%, NY 8.25%,
OH 5.75%, PA 6%,
SC 5%
Check or money order enclosed
(payable to Graco Children’s Products Inc.)
Charge to credit card
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Account #
Expiration date
Signature
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NAME:
ADDRESS:
CITY, STATE, ZIP CODE:
TELEPHONE (including Area Code):
37
