SECURE ORDER FORM EXAMPLE

This is only an EXAMPLE .

SECURE ORDER FORM

This form can be modified in any way you may wish.

Note, that in the lower left corner of your browser window, the

.or.

are now locked. This indicates that all information send from this form

will be encrypted for security reasons.

CREDIT CARD ORDERS

You may also use this form if paying with check/money order

CREDIT CARDS

Packing & Shipping add $4.99
NY residents add 8.25% State Sales Tax (if applicable)

I'm paying with Check
I'm paying with Money Order
Total amount of your check or Money Order

Checks or Money Orders Payable to: Your Company Name here
Your Address here

MasterCard Visa American Express Discover	Card Number:
	Expiration Date:
	Total amount to be charged to your card
Name on Card:
Customer Name:
Company:
Address:
Address 2:
Phone #:
City:		State:	Zip
Other Comments: To order please click on submit order button now (only once)

Customer Support .