Please provide the following information:

Name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
E-mail
Item Description Price Quantity Ext. Price
Comments or Special Requests
Billing Method	Master Card Visa Money Order
Credit Card Number
Expiration Date
CVV Code*	*The CVV Code is a 3 digit code on back of the card in the signature strip on MasterCard or Visa or Discover. On American Express, this is a 4 digit code on the front of the card and above the Credit Card Number.
Card Holder Name
Card Holder Signature

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