BILL TO:

NAME:_____________________________________________

PHONE:____________________________________________

FAX:_______________________________________________

ADDRESS:__________________________________________

CITY, ST, ZIP:_______________________________________

SHIP TO: (check if same as billing)

NAME:_____________________________________________

PHONE:____________________________________________

ADDRESS:__________________________________________

CITY, ST, ZIP:_______________________________________

SHIP VIA: (circle one)

UPS FEDEX OTHER_______________________________

PURCHASE ORDER#_________________________________

Quantity________Catalog#___________Price Each___________Total_________

Quantity________Catalog#___________Price Each___________Total_________

NAME TO BE EMBOSSED:____________________________________________

Second line at $1.00 per book: _________________________________________

Credit Card#_________________________________EXP.DATE:_____________

CARD HOLDER'S NAME:___________________________________________

Other Instructions:___________________________________________________