Name: __________________________________________ FAX: ________________ Phone: _____________________ Address: ________________________ E-Mail: __________ City: ___________________ State: ____ Zip: _______ Country____ Credit Card #: _______________________ Exp. Date: _____ VISA ______ MasterCard ______ Special Instructions: ________________________ Shipping Charges will be added to all orders!

Quantity                Description             Price Each

Ship to:  (if different than above) Name: __________________________________________ Address: ________________________________________ City: __________________ State: ___ Zip: ______ Cty: ___

CONTACT INFORMATION Telephone:  1-515-955-2353 FAX:  1-515-955-6258 E-Mail:  dejavu@dodgenet.com Mailing Address:  1407 1st Ave. So., Fort Dodge, IA  50501 USA