| Name: |
_________________________________ |
| Address: |
_________________________________ |
| Town / City: |
_________________________________ |
| State: |
_________________ |
| Zip Code: |
_________________ |
| Day Phone (+area
code): |
_________________________________ |
| Evening Phone
(+area code): |
_________________________________ |
| E-mail Address |
_________________________________ |
Please
make your selection
(Help us meet your
expectations by ordering only one brick or tablet per order form. Want
more (and we hope that you do), please fill out another order form and submit with your
payment information - Thank You!) |
|
| $100 for one
4" x 8" Brick ____ |
|
| $500 for one
12" x 12" Tablet ____ |
|
| $1000 for one
12" x 24" Tablet ____ |
|
| Please
select credit card or check |
|
| MCard ____
Visa ____ Check ____ |
|
| Card #:
___________________________ |
Expiration date
(mmyyyy): ______________ |
| Name
of credit card holder: |
________________________________ |