Name:        First     Last         Phone:

Email Address:

Street Address    City     State:     Zip:

Standard shipping is UPS Ground

Quantity:         Item #:     Description: Price ea.: Price Total:

Quantity:         Item #:     Description: Price ea.: Price Total:

Quantity:         Item #:     Description: Price ea.: Price Total:

Quantity:         Item #:     Description: Price ea.: Price Total:

Quantity:         Item #:     Description: Price ea.: Price Total:

Quantity:         Item #:     Description: Price ea.: Price Total:

                                                                                                                                                           Subtotal :    

                                                                                                                                                           Tax (.07 %)

                                                                                                                                                           Shipping       $ 5.00

                                                                                                                                                           Grand Total

Pay by Credit Card, Check or Money Order. (If paying by Check or Money Order, please print out Order Form and send with payment.)

Credit Card Information

Card Type: Visa Mastercard    

Name on Card:  First Middle Last

Card Number:             Exp Date:

                                            Thank You For Your Order!