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Shipping Information:
| Name:* | |
| E-mail:* | |
| Address: | |
| City: | |
| State/Province: | |
| Country: | |
| Zip Code: | |
| Phone Number:* |
Billing Information:
(only if different from Shipping)
| Name: | |
| Address: | |
| City: | |
| State/Province: | |
| Country: | |
| Zip Code: |
| Quantity | Item Description | Price | Total |
|---|---|---|---|
| Georgia Resident Sales Tax @ 8% | |||
| Shipping -we will add the shipping - (usually between $4.95 and $6.50) | |||
| CREDIT CARD TYPE | |||
| CREDIT CARD NUMBER | |||
| EXP DATE | |||
| AVS-CODE (last 3 or 4 numbers in signature area) | |||
Additional information, comments or questions: |

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