Please circle your method of payment:
Credit Card: Visa Mastercard Discover American Express,
Money Order, Check
16 Digit # _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ Enter Exp. _ _ /_ _
_ _
3 or 4 digit # on back of Card _ _ _
.
Ship Order to:
Name ___________________________________________ Phone # (______)_____-_______
Address _________________________________________ APT or STE. #________
City ____________________________ State_________ Zip _________
.
Is billing address the same as shipping address? Yes
or No
If no, please give: Billing Address, City, State & Zip
________________________________________________________________
E-Mail _____________________ @___________________________________
