Name_______________________________

 

Address_____________________________

 

City____________________State________ Zip

 

Phone No.__________________

 

Email Address________________________

 

MC/Visa_____________________________3 digit Sec.code___

 

Expiration date____________                          Order date_______

 

      Item #                  Qty.    Description                     Price

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                                                        Total of order:___________

  6.25% Sales Tax-Mass. residents only____________________

   Shipping & Handling_____________________________

   Gift certificate___________________________________

                                                         Total Amount___________