Please fill out this form, then print, sign, and transmit by fax to the facsimile number listed below.

Last Name / Company Name:

First Name / Contact Name:

Telephone Number (confidential, for notification / shipping only):

E-Mail Address (for notification / confirmation):

Billing Address:

Street Address or Postal Box #:

Apt. / Suite No.:

City:

Province / Region:

Postal Code:

Country:

Shipping Address (if different from above):

Street Address or Postal Box #:

Apt. / Suite No.:

City:

Province / Region:

Postal Code:

Country:

ITEMS REQUESTED:

Credit Card Type: Visa MasterCard Discover American Express

Credit Card Account Number:

Expiration Date:

Security / CVL Code:

*Note: For Visa, MasterCard, and Discover cards, this code is the last three digits printed on the card's signature strip (back of card). ***For American Express (AMEX) accounts, this is a four-digit code found on the front of the card following the card number.

FedEx Account Number for FedEx International Shipping:

Due to the high number of fraudulent credit card sales over the internet, we also REQUIRE the following information for ALL international credit card purchases. No order will be shipped until this information has been provided and verified with your bank:

Issuing credit card bank:

Bank's physical address:

Bank's telephone number: