Please include complete street address for UPS delivery

Ordered by:

Name________________________________________

Street________________________________________

City/State/Zip__________________________________

Ship To: (If different):

Name________________________________________

Street________________________________________

City/State/Zip__________________________________

In case we need to contact you about your order please provide:

Phone________________________________________

Email_________________________________________

for special instructions or more order space, please include a
separate sheet of paper

Visa or MC _ _ _ _  _ _ _ _  _ _ _ _   _ _ _ _   EXP: _ _  _ _

Signature:________________________________________

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