Ship To:    Name: _________________________________________

         Address: _________________________________________

                  _________________________________________

                  _________________________________________

I Would Like To Order:
     Quantity        Item Number           Quantity      Item Number

      _____           __________            _____        __________

      _____           __________            _____        __________

Ship Via: Standard Domestic Service / UPS-3Day / UPS-2Day / UPS-Overnight

Type of Credit Card: VISA / MasterCard / AMEX 

Card Number : __________________________________________________________

Expiration Date:(MM/YY)_________________________________________________

Name As On Card :_______________________________________________________

Card Billing Address:___________________________________________________
(If Different)
                     ___________________________________________________

                     ___________________________________________________

Contact Information: Day Time Phone: ___________________________________

                     Fax Number: _______________________________________

                     Evening/Home Phone: _______________________________

                     E-Mail: ___________________________________________