4625 SE 24th Ave · Portland, OR 97202-4796
Phone: 503-235-2171 Fax: 503-234-7142
Phone/Fax: 1-800-605-6301
Internet Order Form
Print this form, fill it out, and mail or fax it in
with your payment
Please write copy in the boxed areas below:
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| Should you wish to provide your credit card information, you may do so in the areas provided below: |
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Name As Shown On Credit Card:____________________________ |
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Credit Card # ______________________ Expiration Date_________ |
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Card Type:_________ MC & Visa Only Signature:_________________ |