Date_______________ your e-mail address_________________________________
Name___________________________________________
Address__________________________________________________________________
City__________________________State_____Zip_________Country_____________
Phone__________________________ (It is important that
we have your phone number, in case we have questions concerning your order.
We will not use your phone number for solicitation.)
| Stock # | Quantity | Description | Price Each | Total Cost |
(Leave blank - we will determine the S&H after we weigh your package) +SHIPPING:$____________________
(Leave blank - we will determine the Total after we calculate S&H charge) TOTAL DUE: $____________________
PAYMENT: (circle one) VISA / MASTER
CARD / AMERICAN EXPRESS / DISCOVER
CREDIT CARD #___________________________________ EXP DATE__________CVV Security Number_______
Name as it appears on card______________________________Your
Signature____________________________
Thank you for your order!
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