Shopping Cart - Order Form

Please fill out the fields below and press submit. The order will be sent to you as soon as possible. All fields are required to process your order, if there is a problem with the information, you will be contacted by e-mail first, then by telephone as soon as possible.


Pay by check or money order

Your email address:

Your phone number (xxx-xxx-xxxx):

Comments:

Shipments requiring multiple cartons may require additional shipping charges not shown at this checkout.  Orders designated as “extended delivery areas” by UPS will require additional shipping charges not reflected at the time of checkout.  Customers may leave comments requesting specific freight charges.


Bill to:

Name

Street

City  State
Zip Code (xxxxx-xxxx)   Country

 

Ship to:

Name

Street

City   State
Zip Code (xxxxx-xxxx)    Country


Credit Card Information:
Credit Card Name:
Credit Card #:

AVS Code:  
MC/Visa: Located On back
AMEX: Located on front

Name as it appears on credit card:
Expiration Date: Month Year