Customer Name :__________________________________________
         As Shown On Credit Card

           Credit Card Number :________________________________________
        Visa, Mastercard, American
                Express, Discover

        Expiration (Month / Year ) :_____________________________________

      Shipping / Billing Address:_______________________________________
                               :
        Address where you receive
        your credit card statements:_____________________________________
      This is the only address where
            we can ship your order

                           City :______________________________________________

               State / Province :__________________________________________

             ZIP / Postal Code :__________________________________________

                       Country :_____________________________________________

             (Area Code) Phone
                       Number :_____________________________________________
         Give country & city codes if
                  outside the USA

          Your E-Mail Address :________________________________________

         RE-ENTER Your Email
                      Address :_____________________________________________

                      Ad Code :_____________________________________________
       Where did you see our ad? If
                 unsure, enter XX

        Website Name ( Primary
                      Choice ) :_____________________________________________
         Maximum 8 characters. No
               spaces, symbols, or
                punctuation marks

       Website Name ( Back-Up
                      Choice ) :_____________________________________________
        In case your Primary Choice
                  is already taken