 |
|
| Order Date |
|
Ship Date |
|
| Visa, Mastercard, Discover, American
Express Card Number |
| Card # |
|
Exp. Date |
|
| Authorized Signature |
|
| Billing Address (As it reads on Credit
Card) |
| Name |
|
| Address |
|
| City |
|
State |
|
Post Code |
|
Country |
|
| Phone |
|
Email |
|
|
Shipping Address If
different from Billing |
| Name |
|
| Address |
|
| City |
|
State |
|
Post Code |
|
Country |
|
| Phone |
|
Email |
|
| |
| Qty. |
Item # |
|
Item Description |
Unit Price |
Total (US $) |
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
|
Shipping & Handling |
|
|
| TX Residents Add 8.25% Sales Tax |
|
|
| Total (US Currency) |
|
|
|
| |
|
|
|
You may place an order by
contacting:
|
|
 |
|
