PLEASE PRINT CLEARLY

NAME:_____________________________________________________________________

ADDRESS:_________________________________________________________________

CITY, STATE ZIP:________________________________________________________

Other:___________________________________________________________________

PHONE:________________________ EMAIL:_________________________________
________________________________________________________________________
QTY-------- ITEM#-------------------DESCRIPTION------------------COST EACH-------TOTAL

___     __________          ___________________________      ________       ________
            
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___     __________          ___________________________      ________       ________

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___     __________          ___________________________      ________       ________

TOTAL: _____________________________________________________ $___________

SHIPPING: ($10.00 or 5% Whichever is Greater)______________________$___________
US Addresses only lower 48 states

GRAND TOTAL: (WV RESIDENTS ADD 6% SALES TAX)______________$___________
____________________________________________________________________________________________



CREDIT CARD INFO: NAME ON CARD______________________________________

CARD NUMBER__________-__________-__________-__________ EXP. DATE_______/_______ 


_________________________________________
CARD AUTHORIZING SIGNATURE