Name: ________________________________________________

Address:________________________________________________

City:___________________________________________________

State/Province:_________________________________________

ZIP/Postal Code:________________________________________

Country:________________________________________________

Credit Card Type:_______________________________________

Credit Card Number:_____________________________________

Expiration Date: _______________________________________

I authorize the purchase of the items listed below to be charged to my credit card, identifying information as shown above.

(Signature of Card Holder) _________________________________________________________

Quantity	Item	Price Each	Price Total
_________	_________________________________	______________	____________
_________	_________________________________	______________	____________
_________	_________________________________	______________	____________
_________	_________________________________	______________	____________
_________	_________________________________	______________	____________
_________	_________________________________	______________	____________
_________	_________________________________	______________	____________

Shipping:_________________________________

Total:____________________________________