First Name:__________________________ Last Name:__________________________

Shipping Address
Street # & Name:_______________________________________

City:___________________ State/Province: __________________

ZIP/Postal Code: _____________ Country:___________________

E-mail:________________________

Phone (work):________________ Best time to call you :_____________ Time Zone:_______

Phone (home):________________ Best time to call you :_____________ Time Zone:_______

(Cheque , Money Order , Credit Card):_________________________

Name on Credit Card:__________________________

Mailing Address
Street # & Name:__________________________________

City:___________________ State/Province: ________________

ZIP/Postal Code: _____________ Country:___________________

Credit Card Type (Visa, Master Card, American Express): ________________

Credit Card No:__________________________ Expiry Date:_________________

                                                                                        Signature:___________________

Customer service phone # on back of credit card:__________________________