Customer Information (* if paying by cheque click here)

     Invoice Number: 
     Customer Number: 1049
     Please enter your shipping and billing information. The following are required:

	First Name:
	Last Name:
	Email:
	Phone:
	Fax:	*Please write "none" if none.
	Billing Information	(* if paying by cheque click here)
	Address:
	Address Line 2:	*Please write "none" if none.
	City:
	State,Province,Region:
	Zip or Postal Code:
	Country:
	Ship To Information
	Ship Address:
	Ship Address Line 2:	*Please write "none" if none.
	Ship City:
	Ship State:
	Ship Zip:
	Ship Country:
	Your purchase will take place on a Secure Server. Please press continue to proceed.