TOTAL COST =
$5.95
Credit Card (Check One):
NOTE: If the
name and address on your Credit Card is the same as the name and address
entered above, just type the word "SAME" in Name Field and proceed to Card
Number and Expiration Date!
Name on Card
Card Billing Address
City State
Zip
Card Number
Example: 1234-5678-9012-3456
Expiration Date
Example: March 2003 = 0303