Customer Information

Credit Card Number (is it Visa , Master Card , Discover ,
American Express other ?)__
Expiration Date (mm/yy)— _
Customer Name (as it appears on the card)__

Billing Address


Total Amount (including any taxes, duty, shipping charges)_____

What Currency (US , Canadian , English , Australian )
(should be US if possible)
Customer Order # (PO, or Invoice #)_______
CW2 (Security numbers on the back of the card as written with appropriate spaces if any)
Approximate Ship Date__