Bill to:

 Date:

 PO No.:

 Ship to:(if different)

 Tel. No.:                               Fax No.:

Party to Contact:

 Method of Payment:  Credit Card / Purchase Order / Company Check

 Credit Card Type:  VISA  /  Master Card  /  American Express  /  Discover

 Credit Card No.:

 Exp. Date:                /

 Card Holder Name:

 Signature:

 Shipping Method: UPS Nextday / 2nd day / 3rd day / 3rd party / Ground / Fed Ex 3rd Party / Pick-up /________