Instructions: Please print this, fill out, and fax to 1-503-761-4680

Bill to:_____________________________     Ship to: __________________________

__________________________________       ________________________________

__________________________________       ________________________________

__________________________________       ________________________________

Phone: ___________________________        Fax:__________________________

                                                        PAYMENT INFORMATON:

CREDIT CARD USED: p Amex      p VISA          p Mastercard

NAME ON CARD: _____________________________________

CREDIT CARD NUMBER: ________________________EXP. DATE: _________

Description	Card #	Qty	Price	Description	Card #	Qty	Price	TOTAL

                                                                       Grand Total: _____________