Purchaser Information:

Name:
Company:
Email:
Phone:
Fax:
Address:
City:
State/Prov:
Zip/Postal:
Country:

Send Your Order To:

Your Name
Your Street Address
Your City, State, Zip
Your Phone and Fax Number

Payment Options

By Credit Card (Mail or Fax)

Credit Card Type:	Select VISA MasterCard Discover AmerExp
Cardholder Name:
Card Number:
Expiration Date:

By Check (Mail or Fax)

Note: All fields must be completed. Fraudulent use of BANK information is strictly prohibited by State and Federal Laws. ALL transactions are logged and any fraudulent activity reported. If time is important to you, use your Credit Card to Order since this process is quicker.

Enter all the numbers on the bottom of your check (use spaces for odd characters):
_________________________________________________

Name on check:__________________________________________

Address on check:________________________________________

City:____________________  State:__________  Zip:___________

Day/Night Phone #'s:___________________ /__________________

What is the FULL check number:_____________________________

Total Check Amount This Order: $____________________________

Your Bank Information

Name of Bank:____________________________________________

Bank Branch Name or Number:______________________________

City:____________________  State:__________  Zip:____________

Phone# of Bank (if not on check)_____________________________

Enter 9 digit routing #:__________________________ (see diagram)

Bank account#:_________________________ Date:____/____/____

VOIDED COPY OF CHECK MUST ALSO BE FAXED
Please FAX to - + (###) ###-#### after you have completed the form.

1. All fields must be filled in. If they are not, orders may not be processed.
2. ALL BAD CHECKS WILL BE CHARGED A $##.00 FEE. NO EXCEPTIONS !

Make Product Selection:

# Description Qty $ Each $ Totals 1. 2. 3. 4. 5. Sub-Total: Select Shipping & Handling: $5 USA   $10 Canada  $24 Outside USA TOTAL ENCLOSED (including S&H) $