Note: if items are to be shipped Courier, please fill in details of Lot, Con, etc, as couriers cannot ship to postal boxes.

Name ___________________________________________________

Mailing address: (street) _____________________________________

City _____________________________________________________

Province ______________________ Postal Code_________________

Home Phone___________________ Work Phone_________________

Email : __________________________________________________

If more space is needed please print 2 copies and fax together

If Payment is by Visa or Mastercard, Please fill in the following information

Check one: Visa_____ Mastercard_____

Card number______________________________________ CVD#__________________________

Expiry Date_______________________________________

Name on Card_____________________________________

Signature of card holder______________________________