Name_________________________________________Title______________________

Street Address__________________________________________________________

City____________________State________________Zip_____________

Phone(___)______________Fax(___)_____________E-Mail_____________________

Shipping Address________________________________________________________

City____________________State________________Zip____________

Visa_____Mastercard_____Check/Money Order____PO#_____(Subject to credit approval)

Credit card number_____________________Exp. Date__________

All orders shipped via UPS ground service unless otherwise requested.


P/N_________________________Qty________Price Each________Total________

P/N_________________________Qty________Price Each________Total________

P/N_________________________Qty________Price Each________Total________

P/N_________________________Qty________Price Each________Total________

P/N_________________________Qty________Price Each________Total________

P/N_________________________Qty________Price Each________Total________

P/N_________________________Qty________Price Each________Total________

P/N_________________________Qty________Price Each________Total________

                                          
Shipping/Handling (U.S. Rates Only)            Product Total__________

Under $15.....$6.40                        Shipping/Handling__________

$15-$24.99....$7.60                           Customs/Duties__________

$25-$39.99....$8.65                                Sales Tax__________

$40-$49.99....$9.70                              Grand Total__________

$50 and Over..$10.90

Comments/Special Instructions____________________________________________

_________________________________________________________________________