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  Shipping Information
    Business Name
    Business Phone   Fax
    Ship to Name
    Ship to Address
    Ship to Address (Cont)
    City State
    Zip Code County
  Hinge Tweaker Order Quantity
    Standard Weight
Hinge Tweaker Qty.		 @  $69.95
 + Sales Tax (PA, OH, NY, WV, CT, VA)
+ $6.00 Shipping and Handling Per Unit
    Heavy Weight
Hinge Tweaker Qty.		 @  $79.95
 + Sales Tax (PA, OH, NY, WV, CT, VA)
+ $6.00 Shipping and Handling Per Unit
  Credit Card Information
    Credit Card Type

MasterCard Visa Discover Card

    Card Number
    Name on Card
    Card Expiration Date Month     Year
    Card Hold Signature _________________________________________

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