Item(s) to Order

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Product Name                     Product No.                       Qty            Price                Total

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Product Name                     Product No.                       Qty            Price                Total

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Product Name                     Product No.                       Qty            Price                Total

Personal Information

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Last Name                                                First Name

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Address

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City                                                          State                             ZIP

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Daytime Phone                                         Evening Phone

Have you ordered from us before? ____  yes     _____ no

Payment Information

___ Check/Money Order
___ Credit Card     (  ) Visa     (  ) MasterCard     (  ) American Express     (  ) Discover

Credit Card # _____________________________________________________________
Credit Expiration__________________________(Month) _____________________ (Year)
Signature ________________________________________________________________

Our staff will contact you at the number listed above to confirm your information and answer 
any questions that you may have. Thank you for your order!