QTY

ITEM # and NAME

PRICE

TOTALS

$

$ 

$

$ 

$

$ 

$

$ 

$

$ 

$

$ 

$

$ 

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$ 

$

$ 

Subtotal

Domestic Shipping
$1- $100  -   Please add 15%
Over $100  -  Please Contact us for shipping rates before you mail your order.
Overseas  
Additional shipping fees will be added to your order
Credit Card payment only

IA Residents Add  7% tax

Shipping

Grand Total

CREDIT CARD INFORMATION

Name on Card -

Card Number -  __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __

Expiration. date                                       CIRCLE ONE:    VISA       M/C      DISCOVER

CUSTOMER INFORMATION

Customer Name

Address

City                                                           State                      Zip Code

Home Phone #                                Work Phone #                                  Email Address