| Billing Address: | Shipping Address: |
Name:_____________________________
Address:__________________________
_____________________________
City:_____________________________
State:______ ZipCode:_____________
Country:__________________________
Phone:____________________________
Fax:______________________________
eMail:____________________________ |
Name:_____________________________
Address:__________________________
_____________________________
City:_____________________________
State:______ ZipCode:_____________
Country:__________________________
Phone:____________________________
Fax:______________________________
eMail:____________________________ |
| Item # | Description | Unit Price | Quantity | Extended Price |
| ____________ | ________________________ | ____________ | _______ | ______________ |
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| ____________ | ________________________ | ____________ | _______ | ______________ |
| ____________ | ________________________ | ____________ | _______ | ______________ |
| ____________ | ________________________ | ____________ | _______ | ______________ |
| ____________ | ________________________ | ____________ | _______ | ______________ |
| ____________ | ________________________ | ____________ | _______ | ______________ |
| ____________ | ________________________ | ____________ | _______ | ______________ |
| ____________ | ________________________ | ____________ | _______ | ______________ |
| ____________ | ________________________ | ____________ | _______ | ______________ |
| ____________ | ________________________ | ____________ | _______ | ______________ |
| ____________ | ________________________ | ____________ | _______ | ______________ |
| ____________ | ________________________ | ____________ | _______ | ______________ |
| ____________ | ________________________ | ____________ | _______ | ______________ |
| Subtotal: | ______________ | |||
| Postage and Handling (See chart on previous page): | ______________ | |||
| (Hawaii Residents Only) State Tax (4.169%): | ______________ | |||
| Total Cost: | ______________ | |||
| Paid by Cashier's Check: | _______ | Money Order:_______ | Credit Card:_______ | |
| Visa:_____ Master Card:_____ American Express:_____ Discover:_____ | ||||
| Card Holder's Name: | _______________________________________ | |||
| Card Number: | ___________________________ | Expiration Date:___/___ | ||
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