Name
Address
City
State		ZIP
Phone		E-mail

Item NAME	Color	Price Each	Quantity	Total
Date of Order:			Total Due $

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Credit Card #		Exp. Date:
Signature

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• [  ] Check here if you wish item to be shipped to address other than indicated above  ... please write person's name and their shipping address on the back of this form.
• THANK YOU FOR YOUR ORDER!

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