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Please print this out and mail the fully completed form to:
Tom Dixon
P.O. Box 671166
Marietta, GA  30066
USA

Or Fax the completed from to (770) 973-9238

Name:____________________________________
Date Ordered______________
Address:__________________________________   City:_____________________  State:_____________
Zip/Postal Code____________
Phone Number______________

#

DESCRIPTION

PRICE EACH

TOTAL PRICE

       
       
       
       
       
       
       
       
       
       
Name of Card Holder:___________________  Merchandise Total:        __________________
Expiry Date: _______ (GA res. add 5% Tax:)   __________________
Visa/Mastercard # ________________________ Shipping Charge:            __________________
TOTAL ENCLOSED     __________________

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