You can print this form after you fill it out by selecting File/Print from your browser.

Mail this form along with your check or money order payment to:
Business Name
Business Address
City, State Zipcode

Credit Card Orders can be faxed to:
1-800-555-1212

Shipping Info:

Name: ____________________________________________
Address:__________________________________________
City:________________________________State:_______
Zip Code: ________________

Payment Info:

Credit Card Type: __Visa   __MasterCard  __Discover 
Credit Card Number: _______________________________
Credit Card Expiration Date Month:____ Year: ______
Name of Cardholder:________________________________
Phone Number:(______) ______-_________

(note: necessary for processing credit card)

Order Info:

                                       Price   Total
Quantity      Description              Each    Price
____________________________________________________
__________|__________________________|_______|______|
__________|__________________________|_______|______|
__________|__________________________|_______|______|
__________|__________________________|_______|______|
__________|__________________________|_______|______|
__________|__________________________|_______|______|
__________|__________________________|_______|______|
__________|__________________________|_______|______|
__________|__________________________|_______|______|
__________|__________________________|_______|______|
__________|__________________________|_______|______|
__________|__________________________|_______|______|
                                    Shipping |______|
                                   Sales Tax |______|
                                       TOTAL |______|