Name:____________________________________________

Address:__________________________________________

City:______________________________________________

State:__________________ Zip Code:___________________

 Daytime Phone:__________________________(Required)

Email Address:________________________________

How did you find us? _________________________

Total

U.S.A. Shipping & Handling per unit ordered*
(see map below)
Eastern U.S. Zone - $15.00 ea.)
Middle U.S. Zone - $20.00 ea.)
Western U.S. Zone - $27.00 ea.)

Please provide the following information if paying by credit card:

Cardholder Name_________________________________

Account Number__________________________________

Expiration Date (MO/YR)____________________________

30 Day Money Back Guarantee
If not completely satisfied, just return it for a complete refund (not including S&H)
You must call for authorization & return instructions.

Print and fax or mail to the address below
We accept checks, money orders and all major credit cards

Shipping Map