Todays Date Cust. Daytime Phone # Cust. Fax#
Customer Name Address
City State Zip Cust. Email
MC/ VISA/ DISCOVER/AMEX NUMBER :
EXP DATE
Security code (located in the signature line last three numbers)
Customer Signature ___________________________________________
If Credit card billing address is different than shipping please fill out forms below
Address City State Zip
Please send my order by (date)-OR-
| QTY | ITEM# | ITEM DESCRIPTION (BE SPECIFIC!) | COLOR | SIZE | PRICE |
| IF ORDER TOTALS... PLEASE ADD $10.00 or less --------------------$6.95 | SUBTOTAL | |
| <------Shipping, Handling, Insurance | ||
| 7% MS Sales Tax | ||
| TOTAL |
Large orders quoted separately