Shipping Address (if different from Billing Address)
Name
Address1
Address2
City
State or other division	select state unlisted Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming enter unlisted here:
Zip Code or other postal code
Country
Telephone (with area code)

Order	Item	Color	Unit Price	Quantity	Line Total
First Item*	*	*	*	1 2 3 4 5 6 7 8 9 10 11 12
Second Item				0 1 2 3 4 5 6 7 8 9 10 11 12
Third Item				0 1 2 3 4 5 6 7 8 9 10 11 12
Fourth Item				0 1 2 3 4 5 6 7 8 9 10 11 12
Total for Merchandise Shipping and Sales Tax will be added as shown above

Credit Card
*exact name on card
* select Visa Mastercard	number with no hyphens*
*expiration:	Month January February March April May June July August September October November December Year 1999 2000 2001 2002 2003

*e-mail address

Comments

We will respond to your order by e-mail and notify you of the amount charged to your credit card, including shipping and sales tax as applicable; we will also advise you of the projected shipping date and method. Please be sure that your e-mail address is entered correctly in the form above. If you do not receive our e-mail response within three days, please e-mail us to check on your order.