E-Clectic Store

Last Name: First Name: Middle:

Home Address: Apt # (If Applicable): State: Zip Code:

Day Phone: Evening Phone:

E-mail Address:

Step 1:

Select Shipping Method

Priority Mail

UPS 2nd Day Air (US only)

UPS 3 Day Select (US only)

UPS Ground (FREE)

UPS Next Day

Step 2:

Select Payment Method

Visa
MasterCard
American Express

Card Number:

Exp. Date: