| Ordered by: | Ship to (if different): |
| Name: | Name: |
| Address: | Address: |
| Address: | Address: |
| City, State, Zip: | City, State, Zip: |
| Country, Province: | Country, Province: |
| Phone: | E-mail: |
| If paying by credit card, please be sure that your name and address are exactly the same as your credit card billing statement. | |
| Quantity | Description | Price Each | Total |
| Kenny Youngblood Prints (Set of 4) | $109.90 | ||
| WI
Sales Tax 5% add $5.50 (Wisconsin Residents Only) |
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| TOTAL | |||
| Method of Payment | ||||
|---|---|---|---|---|
| Check _____ | Bank Check _____ | Money Order ____ | VISA ____ | MasterCard ___ |
| Card Number |
3-digit CVC # (back of card) __ __ __
Exp. Date __ __ - __ __
Signature(for credit card): ___________________________________________