Name
Title
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
FAX
E-mail
URL

QTY	DESCRIPTION	Price each

	BILLING
Purchase order #
Credit Card Orders	Please Call 401-421-0991with your credit card information

*** Credit Card information is sent via Email.  If you are uncomfortable with this method of ordering, please contact us (401-421-0991 or ajdist@verizon.net) for alternative methods of ordering.

	SHIPPING (only if different than above)
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country