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                                 Order Form

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Product name     Abracadabra

Product ID        1333-2


Unit Quantity: ______

Price ($U.S.)   $19.00

TOTAL AMOUNT ($U.S.) __________


Payment Information:


First Name: ____________________________________________

Last Name: _____________________________________________

Company: _______________________________________________

Street Address: ________________________________________

________________________________________________________

City:  _______________________________________________

State/Province: ________________________________________

Zip/Postal Code: _______________________________________

Country: _______________________________________________

Daytime Phone: _________________________________________ 

Fax: ___________________________________________________

Email Address: _________________________________________


Payment:


___ MasterCard ___ VISA ___ AMEX ___ Discover

___ Check ___ Money order


For credit card orders:


Name on Card: __________________________________________

Credit Card Number: ____________________________________

Expiration Date: 
month ________________ year (4 digits) _________________




Signature : ____________________ Date: _________________

