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 Type	Visa   MasterCard	Expire date	Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Credit Card#	***

*** 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