Bill To:
Name______________________________________________________________________
Address____________________________________________________________________
City____________________________________________ State_____ Zip ______________
Phone Number ______ - ____________________
Ship To (if different than Bill To):
Name______________________________________________________________________
Address____________________________________________________________________
City____________________________________________ State_____ Zip ______________
Phone Number ______ - ____________________
| Subtot. | $_______ | |||||
| Shipping | $_______ | |||||
| TOTAL | $_______ | |||||
METHOD OF PAYMENT: (circle one) VISA MC AMEX
Card No._________________________________________________ Exp. Date___________
Signature (as appears on card) ____________________________________________________
______ Check (Please allow 2 weeks for check to clear) ______ Money Order