Name:___________________________________________

Address:_________________________________________

City:________________________

State:________________________

Zip:____________________

E-mail:_______________________________

Payment method: (circle one)  Visa    MasterCard   Amex Discover Check   Money Order PayPal

If paying by credit card, please fill out the following information:

Name as it appears on your credit card:__________________________________

Billing Address of cardholder:___________________________________________

Card Number:___________________________________

Expiration Date:____________

Amount:  $29.95 + 3.20 USPS Priority Mail shipping ($33.15 total)

Please make all checks/money orders out to: PJC Services

Mail to: PJC Services
           512 Northampton St. Dept. I
           Edwardsville, PA  18704

Fax to:  570-288-3536

Please allow 48 hours for credit card and money orders to ship and up to an extra 5 days for check orders to clear.

Thank you for your order!