NAME _________________________________________________________
ADDRESS ______________________________________________________
CITY ___________________________ STATE __________
ZIP ________
PHONE ________/_______________/______________/________________
area
code work home cell
Your email address: ___________________________________________
Shipping Information: (please
skip the "Ship To:" if it's the same as the above)
Ship To:
___________________________________
___________________________________
___________________________________
Method of Payment: m/c ___ visa ___ am/ex ___ disc
___
Card # ___________________________________ expiration
_________
Name on Card _____________________________
If your name is not on the card, are you authorized to use it? _______
check ____ certified funds ____
c.o.d. ____
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