Date: ___________________
Name: ______________________________________________________
Telephone Number: (please *mark* the number where you prefer to be contacted)
Evening ______________________________ Daytime ______________________________
Email: ______________________________________
Address on Credit Card: _______________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Address for Shipping : _________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
| Items Ordered: | Item #_______________ | $_______________ | |
| Description____________________ | | |
| Item #_______________ | $_______________ | |
| Description____________________ | | |
| Subtotal | $_______________ | |
| (Subtract 5% for payment by check or MO) | ($______________) | |
| AZ residents add 6.1% sales tax | $_______________ | |
| Packing/Shipping @ $15/pkg* | $_______________ | |
| Total in U.S. Dollars | $_______________ | |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Credit Card Number: __________________________________________________________
Expiration Date: ______________________
Your name as it reads on your credit card: _________________________________________
V-Code on VISA and MasterCard, C-ID on AmEx: _________________ (V-Code is three numbers in the signature block, following last four digits of VISA & MasterCard numbers. C-ID is four numbers printed on front of AmEx card, above and to the right of card numbers.
Thank you for your business!
©1998 - 2009 CCO *International shipments quoted individually. In general, they will be more than US.