*First Name:

*Last Name:

*E-mail:

*Phone:

*Shipping Address:

*City:

*State:

*Zip Code:

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Check if billing address is same as shipping address

Billing Address:

City:

State:

Zip Code:

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**Payment Type:

Name as it Appears on Card:

Card Number:

Expiration Date:

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*If paying by check or  money order

please make payment out to:

Teresa Lawrence

send payment to:

10419 NE 60th St.

Kirkland, WA 98033