Item Number 1:

Item Number 2:

Item Number 3:

Item Number 4:

Item Number 5:

The Name and Address listed below must be how it appears on the credit card.

First Name:   Middle Initial:   Last Name:

Billing Address:

City:  State:  Zip Code:

E-Mail:   Phone Number:

Payment - If you are faxing this to us, then print out this sheet and write your credit card information on the form before you fax it; you can then fax us at 520-316-0446. If you are transmitting this form via e-mail, then click the submit button below and then call us toll free at 866-464-8893 with your credit card information.