Name:______________________________________________________ Date:_____________ Email:_______________________
Mailing Address, Street:__________________________________________________________
City:________________________________ State: __________Zip:_______________________
Telephone:(______)________________________
Circle your choice of payment:
| MasterCard | Visa | Discover | Am. Exp. | Money Order | Check |
Credit Card No: ________________________________________________Exp. Date:_______
Name on Credit Card: (If other than above):__________________________________________
Billing Address on Card (If other than above):_________________________________________
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Avian 515 Eagle PST 475 (darker)/ 495 (lighter) |
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Add Anti-Reflective Hard Coating ($40.00) |
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| Nevada residents add 7.75% sales tax: | |||
| Add $8.00 Shipping and Handling: | |||
| Total: | |||