Order Date: ___________________________

Bill To:
________________________________________

________________________________________

________________________________________

________________________________________

Phone: ____________________________

E-mail: ____________________________

Ship To:
_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

Payment Information:
Money-orders, Check
Visa and MasterCard Accepted

Please Check Method Of Payment:
Check ___   
Money Order ___ 
Visa ___ MasterCard ___ 
 

Print Name on Credit Card

_________________________________

Address and zip code where the credit card bill statement is sent

______________________________________________________

______________________________________________________

Card Number: __________________________________________

Expiration Date: _____/_____      CVC/CVV#:___________ (Back of Credit Card)


Signature: ______________________________________________

Shipping & Handling Charges: 
For Orders Totaling

0-$10.00                add $2.95
$10.01-$25.00        add $5.95
$25.01to$50.00      add$7.95
$50.01to$75.00      add $10.95
$75.01to$100.00    add$13.95
$100.01 to$150.00  add$15.95
$150.01 to $200.00 add $17.95
$200.01 to $300.0    add 19.95
OVER $300.00       
PLEASE CALL