| Sold
To:
Name__________________________________
Address________________________________
City___________________________________
Zip________________
St._______
Daytime
Phone_________________________
Fax
#__________________________________
|
Shipped
To:
Name__________________________________
Address________________________________
City____________________________________
Zip________________
St._______
Daytime
Phone__________________________
Fax
#___________________________________
|
|
Check One
Charge my:
____
Visa
____
MasterCard
____ Discover
Account:
#_________________________
Amount:
$_________________________
Expiration
Date: ___________________
Credit Card ID Code:
________ Find Location?
Signature__________________________________
|
Check One
____ Money Order
____ Cashiers Check
Amount: $ ______________
*********************************************
Office
Use Only
Received_________________________________
Amt.
$_______________ Per. ________ Co. ________
Company_____________________________________
|
