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					Customer Services: (941) 473-9803 or 866-374-7797

To order by fax, print out this page, fill it in and fax to (941) 475-0218,  to order by phone, simply Call  (941) 473-9803 or 866-374-7797.

Upon receipt of a fax, a member of our customer service department will  contact you to confirm the order.

Ship-to Address

First Name:                   

Last Name:

Address line 1:

Address line 2:

City:

State:

Zip code:

Email:

Phone:   

Credit Card:    

Please select payment type: Visa or Mastercard

Credit card number:

Expiration date:

Cardholder's name:

CVV2 (This is the three extra digits found on the back of your credit card.):

Use the space below to identify the item description and price you wish to purchase.

Only fill in below if your billing address is different to the Ship-to address.

First Name:                   

Last Name:

Address line 1:

Address line 2:

City:

State:

Zip code: