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NOTE: If delivery address and Credit Card Billing Address are different, please include
both addresses. If more space is necessary, please print on a separate sheet
and include with your order.
Payment Method:__Check__Certified Chk__Money Order__VISA__MC
Credit Card#__l__l__l__l__l__l__l__l__l__l__l__l__l__l__l__l
Exp. Date:__l__l__l__l
3 or 4 Digit Security # _1_1_1_1
Signature_______________________________________________
Name as shown on Credit Card:______________________________________
Address________________________City____________State_____Zip_______
(Note: VISA and Mastercard require that you supply your signature and Credit Card billing
address for your protection.) |