NAME:        _________________________________________________________  PHONE: (______)__________________________


ADDRESS: __________________________________________________________E-MAIL ADDRESS:_________________________


CITY:         _________________________________________________________   STATE:_____________ ZIP:_________________

Please enclose pre payment by check and mail to above address - OR give credit card information and fax or mail to us. 

TYPE OF CREDIT CARD: ________________________  CARD NUMBER: _______________________________________________


NAME ON CARD: ______________________________________________ EXP.DATE (month/year):____________ / ____________


CARDHOLDER'S SIGNATURE: ___________________________________________________________________________________