QTY	DESCRIPTION

Please provide the following ordering information:

	BILLING
Credit Card	VISA MasterCard American Express Diner's Club Discover
Cardholder Name
Card Number
Expiration Date

	ORDERING
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
	SHIPPING (if different than above)
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country