(     )

I hereby authorize                              to charge my Credit Card for the amount described below for the merchandise and/or services requested by phone/fax.

(     )

I also authorize the delivery of the merchandise, which I have ordered, to be delivered at the address below specified.

(     )

And in this act I am releasing                            
of any responsibility for the transportation and delivery of the merchandise.

(     )

I agree, in all cases, to pay the Credit Card amount below for the purchase of the ordered merchandise.

Phone:

Fax:

State:

Zip Code:

Country: