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Note: There is no tax on Web Purchases

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Address ________________________________________________________

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Payment Form: __ Check __ Master Card __ Visa

Credit Card __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ exp __/____

______________________________ Signature

______________________________ Name as it appears on card if different from above

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Ship to ________________________________________________

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