Subtotal:
Shipping:
Sales Tax:
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Ship To:
Leave blank if SAME as Bill To
Person or Business name on bank acct:
Person Name:
Name of person placing order:
Company:
Mailing Address:
Street Address:
Apt/Suite:
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Day Phone:XXX-XXX-XXXX
We do not ship to PO Boxes
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* * * * Pay to the Order of Glenn Welt $ _______________________________________________________________ Dollars For ______________________ This draft pre-authorized by accountholder * * use letter "D" in place of