Your Name:___________________________________________________________________________

Payment Type:   VISA    MASTERCARD    DISCOVER   AMERICAN EXPRESS   HOUSE ACCOUNT

Credit Card Number:__________________________________  expiration date:______________

Credit Card Security Code (CVV):____________
This is a three or four digit number on the back of your card, in the signature area. 
For American Express cards, this number is printed on the front of your card, to the
right and above your card number.

Billing Address:_____________________________________________________________________

City, State: ______________________________________   Zip Code:______________________


***Daytime Phone Number:_____________________________________________________________

***We will telephone you to confirm your order once we receive it.  
If we are not able to get ahold of you, there is the possibility 
that your order will not be delivered.***


Item:________________________________________________________________________________

Additional Notes:____________________________________________________________________

Price (including delivery fee):_____________________  Delivery Date:_________________


Send to:_____________________________________________________________________________

Address:_____________________________________________________________________________

_____________________________________________________________________________________

City, State: _____________________________________   Zip Code:_______________________

Phone Number:________________________________________________________________________

Card Message:________________________________________________________________________

_____________________________________________________________________________________