QTY

ITEM AND DESCRIPTION

PRICE

TOTALS

$

$ 

$

$ 

$

$ 

$

$ 

$

$ 

$

$ 

$

$ 

$

$ 

$

$ 

Iowa residents add 7% sales tax                             

Shipping & Handling

TOTAL ORDER

CREDIT CARD INFORMATION

Name on Card –

Card Number –

Exp.date                     Circle One: VISA    M/C                Security Code: (Last 3 digits from back of card) REQUIRED  __ __ __                   

CUSTOMER BILLING INFORMATION

Customer Name

Address

City                                                           State                      Zip Code

Home Phone #                                Work Phone #                                    Email Address