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- PLEASE FILL OUT YOUR PURCHASE REQUEST BELOW -
ITEM	CODE	COLOUR	SIZE	$ PRICE	QTY(S)	SUBTOTALS	$ UPDATE
1				$		$
2				$		$
3				$		$
4				$		$
5				$		$
GRAND TOTALS :						$
NOTE: MINIMUM $30.00 PURCHASE REQUIRED FOR DELIVERY.

PLEASE FILL OUT YOUR INFORMATION (ALL FIELDS REQUIRED)

NAME: (AS DISPLAYED ON YOUR CHARGE CARD)

SHIPPING ADDRESS:

PROV./STATE:

POSTAL/ZIP CODE:

COUNTRY:

TEL.: (INCLUDE AREA CODE)

E-MAIL:

METHOD OF PURCHASE:BY ACCOUNT NOTE: A REPRESENTATIVE WILL NOTIFY YOU FOR CREDIT VERIFICATION.

SHIPPING & HANDLING:

NORTH AMERICAN ORDERS ADD $15.00
OTHER COUNTRIES $20.00

ALL APPLICABLE TAXES ARE INCLUDED IN PRICE.