QTY	ITEM # and NAME	PRICE	TOTALS
		$	$
		$	$
		$	$
		$	$
		$	$
		$	$
		$	$
		$	$
		$	$
PA Residents Add   6% tax -
Shipping and Handling : $00.00 - $ 10.00 $10.01 - $ 15.00 $15.01 - $ 30.00 $30.01 - $ 50.00 $50.01 - $ 75.00 $75.01 - $100.00 Over ..... $101.00 $ 4.95 $ 5.95 $ 7.95 $ 8.95 $10.95 $12.95 $13.95		Shipping & Handling
		TOTAL ORDER

CREDIT CARD INFORMATION

Name on Card -

Card Number -

Exp.date:                   Circle One:  VISA                    M/C

CUSTOMER INFORMATION

Customer Name

Address

City                                                           State                      Zip Code

Home Phone #                                Work Phone #                                    Email Address