Name:________________________________________
	
  Address:_____________________________________   Apt#/Box#:___________________________
	
  City:____________________   State:__________    Zip:___________  Country:____________	

  E-mail:______________________________________

	
  Form of Payment:	_______ Money Order 


			_______ Check 


			_______	Credit Card (fill out credit card section below)

	
  Item Description 			Qty.		Price Each	Total

  _________________________________	_____		__________	_________

  _________________________________	_____		__________	_________

  _________________________________	_____		__________	_________

  _________________________________	_____		__________	_________

  _________________________________	_____		__________	_________

  _________________________________	_____		__________	_________

  _________________________________	_____		__________	_________

 
						 Merchandise Total:	_________

				Ohio Residents add 5.75% Sales Tax:	_________

						 Shipping/Handling:	_________

						       Order Total:	_________

  Credit Card Sales:

  Visa____ M/C____ Dis____ CC#______________________   Expir. Date: ___________

  Signature________________________3-digit verification code (above signature strip) _____

  Check here to have you CC# kept on file for future purchases (you will 
  receive a confirmation via e-mail prior to any items being charged)     ________