Please provide the following contact information:

First Name
Last Name
Middle Initial
Street Address
Address (cont.)
City
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Zip/Postal Code
Home Phone
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Please provide the following ordering information:

QTY	DESCRIPTION
	Pre-Order Price (Single): $13.00 + tax (7%)
	Pre-Order Price (Double): $20.00 + tax (7%)

	SHIPPING
Street Address
Address (cont.)
City
State
Zip/Postal Code

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Please add any additional comments about your order here: