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| 5109 Georgia Avenue | Order # ___________________ |
| Nashville, TN 37209 | Date _____________ |
| Phone/FAX (615) 292-5196 |
| Customer Billing Address (must be same as card) | Shipping Address (if different) |
| Name | __________ | __________ | __________ | _______ | Name | __________ | __________ | __________ | |
| Address | __________ | __________ | __________ | _______ | Address | __________ | __________ | __________ | |
| City | __________ | ____ State | _______ Zip | _______ | City | __________ | __________ | __________ | |
| Phone | __________ | ____ Email | __________ | _______ | State | ________ | Zip | __________ |
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| _______________ | ___________________ | _________________________________ | __________ | ___________ | ||||||||||||
| Sub-total | $ | |||||||||||||||
| Payment Details
Don't send cash O Money Order |
Ship/Hand/Insurance
$10 (Orders to $100)
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48 states |
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| Credit Card #______-______-______-______ | Comments: |
| Expires ___/___ Visa __ Mastercard __ AmEx __ Discover __ | |
| Signature _____________________________ |
| Please indicate if backorders should be __Cancelled __Shipped
when available (up to 4 weeks)
If a price change occurs: __Ship and bill any difference __Notify me before shipping if over 10% Order is from catalog #_______, ___Website, Other:________________________________ |