NAME AS APPEARS ON CARD:

ACCOUNT NUMBER:

EXPIRATION DATE:________________ TYPE OF CARD:    VISA    MASTER   CARD   AMEX ( Circle One)

SIGNATURE: X _______________________________.DATE __________
Please Note: All credit card purchases are subject to2.5% or 0.025 on total amount charged.
All sales are F.O.B. Chicago, IL . packed for domestic shipment .
This section must be filled:

Billing address of card:

Street Address:

City:                                              State:                 ZIP Code:

Tel:                                                   Fax:

SHIP TO:                              IS SHIP TO ADDRESS:      BUSINESS   RESIDENTIAL   (Circle One)

BUSINESS NAME:                                                                 INDIVIDUAL NAME:

STREET ADDRESS:

CITY:                                                              STATE:             ZIP:

SHIP BY: (Circle option)  UPS ,  PREPAID,  COLLECT , INSURED ,  UPS ACT#