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Billing Information

Secure Online
Order Form

Shipping Information

Full Name

Address Line 1

Address Line 2

City, State, Zip

Country

Day: ( ) Night:( )

Phone Number

Fields highlighted in

Yellow

are required.

If mailing this form, please include
     personal check or money order.
Fax, Online or Phone Orders: please include
     credit card information.
Credit card payments: The billing name and
     and address must match the name and
     address on your credit card statement exactly.

E-Mail Address

Payment Method

Credit Card#:

- - -

Payment ID

Expiration Date:

Enter CID number on the credit card:
Click HERE for an example of the CID

CID Number

Description

Part#

Type

Color

Price

Quantity

Total

Orders	Estimated Shipping
under $20	$7.00
$20-$49	$8.00
$50-$74	$9.00
$75-$99	$10.00
$100-$199	$12.50
$200 or more	Please Call/Email

Subtotal

Adjustments

	Calif. Resident?		Yes		No	8.25% CA Sales Tax

Est. Shipping Charges (Actual costs may vary)

Special Charges

Total

Over $200.00 or for unusually heavy or bulky items, Shipping/Handling/Insurance charges will vary.
Foreign Orders: Add $15.00 to the estimate above. Please call for shipping costs outside the USA.
There is a $50 minimum on foreign orders.

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