Billing Address
(Please Print) 		    Shipping Address
(Please Print)
Name _________________________

Name _________________________

Address _______________________Address________________________
            (No PO BOX for UPS Shipping)
City __________________________City ___________________________
State _______ Zip______________State _______ Zip_____________
Phone (      ) ____________________ *ALL SHIPMENTS VIA UPS

1Name of Item Qty.Price EachTotal
2    $
3    
4    
5    
6    
7    
8    
9    
10    
11    
12    
Total 
Mass Residents Add 5% Sales Tax 
Total$
* UPS Shipping Charges to be added

___Mastercard       ___Visa

Credit Card #____________________________________ EXP___________

Name as it appears on Card______________________________