| Date: | Sent By: | |
| Name: | Day Phone: | |
| Billing Address: | Evening Phone: | |
| Fax: | ||
| City/State/Zip: | E-Mail: | |
| Region: | Credit Card: | |
| Country: | ||
| Delivery Address: | Expiration Date: | |
| City/State/Zip: | Deliver By: | ( ) U.P.S. (ground service is standard) |
| Region: | ( ) U.P.S. 2 Day Air | |
| Country: | ( ) U.P.S. Next Day Air | |
| Delivery Phone: | ||
| Quantity Ordered | Quantity Shipped | Size | Item | Unit Price | Total Price | Notes | |
Insurance |
SubTotal |
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Air Shipment |
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C. O. D. - Add $6.00 |
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International Handling |
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International Shipping |
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Insurance |
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ORDER TOTAL |
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