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APPLICATION TO PURCHASE HELIUM
FROM 
BUREAU OF MINES

Prepared ________________ concerning 
Application No. __________ dated ______
NAME OF APPLICANT________
ADDRESS________

Quantity of helium applied for ______ units
Estimated cost per unit of helium ...............$__
The above estimated cost (has) (has not) been approved by the Secretary of the Interior. (If not yet approved this estimated cost will be submitted for the Secretary's consideration before or simultaneously with submission of the contract.)
Estimated cost per unit of helium multiplied by number of units $____
Estimated service charges ................... $ ____
Initial deposit required with contract
(______% of estimated cost plus service charges).......$____

[[Table with three columns, each with 2 sub columns]]
Estimated Deposit Schedule | Estimate Shipping Schedule | Shipment Made (This Column is for recording by Bureau of Mines and is not a part of the report)
Date | Amount | Date | Amount | Date | Amount |

DETAILED ESTIMATES OF SERVICE CHARGES ON REVERSE SIDE 

Supervising Engineer, Bureau of Mines Helium Planty