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
Customer P.O. (if available)
PRODUCT INFORMATION
ITEM CODE OR DESCRIPTION
QTY
1
2
3
4
5
You may use the comments section below if you need to add more items.
More products may be added into the COMMENTS area below
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
$35.00
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
