Total Value of Order (not including Shipping):

Add International Shipping Charge $50.00 US / or provide your UPS account #

Total Value of Order (including Shipping):

Billing Information:


First Name: _____________________________

Last Name: _____________________________

Company: ______________________________

Address: _______________________________

City: __________________________________

State/Province: __________________________

Postal Code: ____________________________

Country: _______________________________

Phone: ________________________________

Fax: __________________________________

Email: _________________________________

UPS account number: _____________________

Shipping Information:


First Name: _____________________________

Last Name: _____________________________

Company: ______________________________

Address: _______________________________

City: __________________________________

State/Province: __________________________

Postal Code: ____________________________

Country: _______________________________

Phone: ________________________________

Fax: __________________________________

Email: _________________________________

UPS account number: _____________________