| (A) Ship To:
(name and address) |
(B) Bill To:
(if different from Ship To) |
| Name: _________________________ |
Name: _____________________ |
| Address: _______________________ |
E-mail: _____________________ |
| Address:_______________________ |
Address: ___________________ |
| City:_________ State:___ Zip:______ |
Address: ___________________ |
| Telephone:_____________________ |
City:________ State:___ Zip:____ |
| |
Daytime Telephone:____________ |
Credit card #____________________________ &
exp. date:____________