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online order form

Online Order Form

# Fields must be filled up for submission 

 First Name  # 
 Last Name # 
 Email Address 
 Address Line1 # 
 Address Line2   
 City #
 State #  Zip # 
 Daytime Phone 
Simple Order Form Via Email Submission
Item Name Qty @Price SubTotal
Sales Tax: Sales Tax will be computed automatically for Residents in: PA
Shipping&Handling: If subtotal is 1-49=$15, 50-99=$10, 100-149=$5, >150=free!