Name:_______________________  ________  _____________________________
             (first)                             (m)            (last)

Address:_____________________________________________________________

City:___________________________ State:______________ Zip:______________

Distributor Name__________________________Distributor #____________

Item #(if you know it)      Item                   Amount     Cost each        Total

______ ______________________________ _________ ___________ __________

______ ______________________________ _________ ___________ __________

______ ______________________________ _________ ___________ __________

______ ______________________________ _________ ___________ __________

______ ______________________________ _________ ___________ __________

______ ______________________________ _________ ___________ __________

Credit Card:  Type:______________________________________
                          (Visa, Mastercard, Discover, etc.)
Name on the Card:_______________________________________

Credit Card Number:______________________________________

Expiration Date:  ____________   _________________
                             (month)          (Year)