Ship To:

Date:

Mailing Address:

Daytime Phone:

E-mail Address:

FOR CHARGE CARDS

Credit Card Type (circle one):

MasterCard

Visa

Cardholder's Name (as it appears on the card):

Account Number:

Expiration (MM/YY):

V-Code (last 3 digits on signature panel):

Authorized Signature:

QTY

STYLE #

DESCRIPTION

AMOUNT

SUBTOTAL

U.S. orders LESS than $20, Add $3.OO

6.875% TAX (New Mexico addresses ONLY)

CANADA add $10 if SUBTOTAL is less than $100, $20 if $100 or more

TOTAL CHARGES