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PURCHASER: NAME __________________________________________________________

STREET ADDRESS _______________________________________________________________

CITY _______________________ PROV./STATE _______ COUNTRY _______________________

POSTAL CODE/ZIP CODE ____________________ PHONE NO. (____) _______________________

SHIP TO (if different from puchaser info above):

NAME __________________________________________________________________________

STREET ADDRESS _______________________________________ CITY _____________________

PROV./STATE _______ COUNTRY ______________ POSTAL CODE/ZIP CODE _________________

PAYMENT INFORMATION: CHEQUE _____ MONEY ORDER ______ VISA ______

NAME ON VISA CARD __________________________________________________

CARD NUMBER__________________________________ EXPIRY DATE _______________

PLEASE NOTE ORDERS WILL BE SHIPPED ONCE FULL PAYMENT HAS BEEN RECEIVED.
PLEASE ALLOW UP TO 4 WEEKS FOR PROCESSING AND SHIPPING.
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