Name:
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Address:
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City: State: ZIP:
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Charge Card Info: [ ] MasterCard [ ] Visa
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Number:
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Expires:
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3-Digit Verification Number:
(The last three digits in the signature panel on the back of your credit card.) |
Phone Number:
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Fax Number:
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Email Address:
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Your Draft Date:
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[ ] AL EZDraft Kits at $20 Each, plus $7.00 Each Shipping and Handling
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$
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[ ] NL EZDraft Kits at $20 Each, plus $7.00 Each Shipping and Handling
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$
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[ ] AL/NL Ultimate Combo EZDraft Kits at $30 Each, plus $10.00 Each Shipping and Handling
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$
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PA Residents Must Add 6% Sales Tax:
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$
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Total Due:
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$
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