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