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On-Line Order Form


Purchased by:
(Billing address for credit card)
Name:

Phone:

E-Mail:

Company:

Street:

City:

State:

Country:

Zip:

Ship to:
(No P.O. boxes)
Name:

Phone:

E-Mail:

Company:

Street:

City:

State:

Country:

Zip:

Stock No. Product Name Size Quantity Unit Price Total Price

Payment Method:
Amer. Exp.*
Discover*
Mastercard*
Visa* 		Check
Money Order
Bank Wire
P.O. Attached

Credit Card Number
Expiration Date
Subtotal
Discount or Surcharge
Subtotal
Call for freight quote
Subtotal
CA residents add 8.25% sales tax
TOTAL (US currency)
  
*I hereby attest that I am the user of the card identified above and authorize the issuer to pay the amount shown as total upon presentation. I promise to pay such total (together with any other charges due thereon) subject to and in accordance with the Agreement governing the use of this card.