Billing Information
Name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
E-mail

	Shipping Information ( if different than bill to)
Name
Street address
Address (cont.)
City
State/Province
Zip/Postal code

Your Daytime Telephone # is important should we have a question about your order:
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(Orders may also be faxed to 404-505-8866 24 hours daily or call 1-800-720-0666.)

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Please provide the following ordering information: (go to shipping costs)

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Qty	Product Code	Description	Unit Price	Total
		Shipping Costs
		All Total

Confirmation of your order will be communicated to you within 24 hours.

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