Name __________________________________________________________________
Address ________________________________________________________________
City ____________________________ State _________________ Zip _____________
Home Phone (________)____________________________________________________
Business Phone (________)_________________________________________________
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Shipping Address (if different than Ordered by):
Name __________________________________________________________________
Address ________________________________________________________________
City ____________________________ State _________________ Zip _____________
Home Phone (________)____________________________________________________
Business Phone (________)_________________________________________________
ITEM # ____________________AMOUNT_________________
ITEM # ____________________AMOUNT_________________
ITEM # ____________________AMOUNT_________________
Note: Please allow 4-6 weeks delivery.
Shipping and Handling_____________ Sub Total _____________ Total__________________
Method of Payment: Credit Card- Money Order- Check (CHECK #_______)
Credit Card (Master Card--Visa--American Express)
