Shipping Information:

Name: ___________________________________________________________________________

Address: ___________________________________________________________________________

              ___________________________________________________________________________

              ___________________________________________________________________________

E-mail address (optional) will only be used to send shipment confirmation:

___________________________________________________________________________

QTY     SKU           ITEM                                                                                                             TOTAL

___________________________________________________________________________

___________________________________________________________________________

Subtotal_________________

Shipping_________________

CA residents only, add 8.975% salestax_________________

Grand Total_________________

Payment Information:

Charge my (circle one):     Visa        Mastercard          Discover           Amex

Card#_________________________________________________________

Exp.Date_____________________CVV2*__________________

*The CVV2 is the 3 digit numeric code after the credit card number on the signature panel.

For Amex, it is the 4 digit code found in the top right corner on the front of the card.

Signature (required for credit card orders):

__________________________________________________________

Daytime Phone Number:

__________________________________________________________