* = REQUIRED

First Name: Last Name: *
E-Mail Address: *
Address:
City: State: Zip:
Country:
Day Phone: * Evening Phone: *

Is this your
work address: or Home address?

Payment by: --- Visa Master Card

Credit Card Number: Exp. Date:
Full name as it appears on the Credit Card:

If payment by Charge Card,

• Please fill in ALL the information above.

• The address you entered above MUST be the address of the Credit Card holder.

• All Credit Card orders will be verified by phone or E-mail before shipping.

• The card holder must include their billing address of card for verification.

• Shipping costs (and Tax if NYS) will be added to your total order.

Comments:

4.00 shipping each item
NYS Residents 8.5% sales tax

---OR---

To Order Call: 516-933-1111