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| Payment Information: Checks must have your name preprinted on them. Returned checks are subject to service charge for the greater of $15 or maximum amount allowed by state law. |
PLEASE PROVIDED A STREET ADDRESS AS UPS |
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AND FED-EX WILL NOT DELIVER TO A P.O. BOX |
| Credit Card Payment Option: |
Ship To Info: |
| VISA
MasterCard
Discover AMEX |
Name: __________________________________________ |
| Card # ________________________________________ |
Address: ________________________________________ |
| Exp: ____________ M/Y |
City: ___________________________________________ |
| Signature _____________________________________ |
State: _________________ ZIP: ____________________ |
| Print Name: ___________________________________ |
Phone: _________________________________________ |
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E-Mail: _________________________________________ |
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Mail This Order Form with Check or Money Order To: |
Allow 7-10 Business Days For Delivery. |
Dirt Wear Mall |
Comments: _________________________________________________________ |
3518 FireThorn Drive |
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Whitestown, IN 46075 |
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