| ORDER FROM:
_________________________________ _________________________________ _________________________________
|
SHIP TO (IF DIFFERENT)
_________________________________ _________________________________ _________________________________
|
NAME: ______________________________________________________________________
PHONE: _______________________________E-MAIL ADDRESS: _____________________
AMOUNT ENCLOSED: ______________________________________________
CREDIT CARD INFO:
Card Type: _________________________________(Visa/MC)(Sorry we do not take AMEX) Card # _________________________________________ Card Expiration __________________________________ Card Name _____________________________________
ITEMS REQUESTED
| Item Number or Description | Number | Price Each | Total Price |
|
|
|||
| Add 7.25% Sales Tax for Nevada Residents. | |||
| TOTAL REMITTED |
Signature:___________________________
Thanks,
Larry Simons