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PLEASE SEND THE FOLLOWING ITEM(S): ________________________________________________ $ ___________ ________________________________________________ $ ___________ ________________________________________________ $ ___________ ________________________________________________ $ ___________ TOTAL $ ____________ I AGREE TO PAY SHIPPING AND HANDLING PRICE* (YES) BILLING ADDRESS_____________________________________________________ NAME (AS ON CARD) __________________________________________________ BUSINESS ___________________________________________________________ ADDRESS ____________________________________________________________ CITY __________________________________ STATE ________ ZIP _________ COUNTRY ______________________ PHONE (REQUIRED)_____________________ FAX __________________________ EMAIL(REQUIRED): ____________________ PAYMENT BY: ( ) VISA ( ) BANKCARD ( ) AMERICAN EXPRESS ( ) DINERS CLUB CARD NUMBER: ________________________________ EXP DATE: _______________ VERIFICATION NUMBER __________ OWNER SIGNATURE ______________ SHIP TO: (IF DIFFERENT FROM ABOUVE) NANE _______________________________________________________________ ADDRESS ____________________________________________________________ CITY __________________________________ STATE ________ ZIP _________ COUNTRY ___________________________ PHONE __________________________