Name  Address

City/State   Zip Phone   Fax

E-Mail Address

Item # Description   Qty

Item # Description   Qty

Item # Description   Qty

Item # Description   Qty

For additional items use separate sheet of paper

Shipping & Handling - $4.95, 1st item + $2. each additional item                   

MS residents add 7% sales tax                                                                            

Total of Order                                                                                                         

Method of Payment  Check or money order enclosed    MasterCard      Visa

Account Number ---    Expiration Date (month, year) -

Cardholder's Name (as it appears on card)

Cardholder's Address (as it appears on account) if different from above

Orders can be emailed by clicking on the submit button below.  If paying by check or money order, we'll ship

 your order on receipt of payment and printed/signed copy of this form to Service Connection, Inc, P.O. Box 10, Horn Lake, MS  38637.

                       We look forward to serving you.  Please allow 2-3 weeks for delivery