FAX ORDER FORM

SHIPPING INFORMATION 
 
        Name _______________________________

 
     Address _______________________________
 
             _______________________________
 
             _______________________________


   Phone No. _______________________________


  
    We will bill your Credit Card $4.95 for 
    shipping and handling.
 


CREDIT CARD INFORMATION
 
  Card Type   []Visa   []MasterCard   []Amex
 
     Name on Card __________________________


      Card Number __________________________
 
  Expiration Date __________________________
 
        Signature __________________________