Customer Information
				Bill To	Ship To (If Different from Bill To)
Customer Name
Street address
Address (cont.)
City
State/Province
Zip Code
Contact Name
Email Address
Phone
FAX

Payment Method
Check or Money Order		Credit Card (fill out this blue section)
Charge against open account / request credit application		VISA MasterCard American Express Discover
Ship COD
Contact me by telephone
Call me with pricing first		Card No.:
		Expiration Date (MM/YY):

Questions or Comments?