Please Fill In These Blanks

Ship To Address:

Name:___________________________________________________________

Organization: _____________________________________________________

Address:_________________________________________________________

________________________________________________________________

City: _________________________________ State:______________________

Country:_____________________________ Zip Code:_____________________

Phone:______________ Fax:_______________ email:______________________

Shipping : UPS Ground *

Payment Method (Circle One): CHECK * CREDIT CARD *

Credit Card (Circle One): VISA * MASTERCARD * DISCOVER * AMERICAN EXPRESS

Credit Card #: _____________ _____________ _____________ _____________

Expiration Date on card (ie. 12-01): _________

Signature (required):_______________________________________

Billing Name and Address of credit card (if different than 'Ship To' address):

Name:___________________________________________________________

Address:_________________________________________________________

________________________________________________________________

City: _________________________________ State:______________________

Country:_____________________________ Zip Code:_____________________

Phone:______________ Fax:_______________ email:______________________