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Ordering by Credit Card

To Order by Credit Card, Fill Out and Submit This Form. To Order by Check, Print This Form and Mail to:

Please provide the following contact information:

First Name
Last Name
Middle Initial
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail

Please provide the following product information:

Product Name
Model

Please provide the following ordering information:

QTY DESCRIPTION

1

Shipping and Handling @ $6.95

 

BILLING
Credit Card
Cardholder Name
Card Number
Expiration Date

 

SHIPPING
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country


Copyright 2001 Custom Publishing. All rights reserved.
Revised: August 26, 2001