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Instructions:
Please print this form, fill it out, and fax it to (704) 633-6262
Qty Manufacturer Description Color Size Price
 
 
 
 
 
 
 
  Subtotal: 
  Sales Tax: 
  ** Shipping:  FREE!
  *** TOTAL: 
**    FREE shipping and handling within the Continental United States.
***    You will be contacted if the actual total differs.
 
Payment Information:
How do you wish to pay?  Please check a payment method and/or fill in required information.
_____ Visa     _____ MasterCard     _____ Discover     _____ American Express
Credit card number: __________________________________     Exp. Date: _____________
Name on card: (please print)  __________________________________    
Signature: (required) __________________________________    
E-mail address:
Billing Address:
Name:  
Street Address:  
City:  
State:  
Zip Code:  
Daytime Phone:  
Evening Phone:  
Shipping Address: (if different from billing address)
Name:  
Street Address:  
City:  
State:  
Zip Code:  
Daytime Phone:  
Evening Phone:  
Special Instructions and Comments:
 
 
 
 
 
THANK YOU FOR YOUR ORDER!