CREDIT CARD BILLING ADDRESS:	MERCHANDISE SHIP TO ADDRESS:
Name:  _____________________________________	Name: ________________________________________
Address: ____________________________________	Address: ______________________________________
City: _______________________________________	City: _________________________________________
State: ______      ZIP: _________-________	State: ______      ZIP: _________-________
Contact Name: _______________________________	Daytime Phone #: _______________________________
Email: ______________________________________	Fax #: ________________________________________

Item Number	Quantity	Item Color	Imprint Color(s)	Imprint Location

Item Description: ______________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________

Credit Card #:_______________________________________________  Exp. Date: ___________________

Credit Card 3/4 Digit Security Code: ____________________

Card Holder's Name As Imprinted On Card (PRINT): _____________________________________________

Card Holder's Signature: __________________________________________________________________

Virginia Residents Add 5% Sales Tax Unsigned orders or orders without the credit card security code WILL NOT BE PROCESSED.