| [] Personal Check Enclosed |
Date Received ___________ |
| [] Certified Check or Money Order |
Check # _______________ |
| [] Ship C.O.D. |
| [] VISA | [] MasterCard |
| [] Discover | [] American Express |
| Card # ________________________________ |
| Card Holder's Name ________________________________ |
| Expiration Date ____________________________________ |
| ________________________________________________ |
| Card Holder's Signature |
| Order R'cvd Date___________ Clerk_____________ |
|
| Continental U.S. Standard Shipping Rates* |
|---|
| $50.00 and under........$4.95 | $100.00 to $200.00.......$8.95 |
| $50.01 to $100.00.......$6.95 | $200.00 to $500.00.......$10.95 |
|   | Over $500.00.....Add 2% |
| *Rates are for UPS Ground deliverable addresses only. |
|