Print and fax to: 540-382-2716   Date: ___/___/___

Contact Name: _________________________________________

Company: _____________________________________________

Address: ______________________________________________

City: ______________________ St: _____ Zip: ________-______

Phone: _____-_____-_________ Fax: _____-_____-___________

Email: ______________________________@________________

[_] Members $17.95 (includes shipping & sales tax)

[_] Non-Members $22.95 (includes shipping & sales tax)

Enclosed is check # ___________ for $______.95

Credit Card #:___________________________________________

Exp.Date: ___/____ Signature: _____________________________
Visa, MasterCard, Discover, American Express