Checkout Order Form
CUSTOMER INFORMATION
Name *
Phone *
Email *
Fax
BILLING
(required)
Address Line 1 *
Address Line 2
City *
State, Province or Region *
Zip/Postal Code *
PO Box (if applicable)
Country
SHIPPING
(if different from Billing)
Address Line 1
Address Line 2
City
State, Province or Region
Zip/Postal Code
PO Box (if applicable)
Country
NOTE:
$5.50
handling fee on all orders.
Due to the high cost of handling and processing orders, we cannot accept any orders less than
$50.00
PRODUCT INFORMATION
ITEM CODE OR DESCRIPTION
QTY
1
2
3
4
5
More products may be added into the COMMENTS area below
Comments
CREDIT CARD INFORMATION
Name On Card
Card Type (select)
Visa
MasterCard
Discover
American Express
Email Request (No CC required)
Card Number
Card Expiration Date
CVV Pin #
What's the pin?
PHONE: 920-837-2526
FAX: 920-837-2530
