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This is an explanation of the purpose of the form ...

Please provide the following contact information:

            Name 
  Street Address 
 Address (cont.) 
            City 
  State/Province 
 Zip/Postal Code 
         Country 
      Work Phone 
          E-mail 

Please provide the following ordering information:

QTY     DESCRIPTION
 
 
 
 
 
 
 
 
 
 

                 SHIPPING
  Street Address 
 Address (cont.) 
            City 
  State/Province 
 Zip/Postal Code 
         Country 

Author information goes here.
Copyright � 1999 [OrganizationName]. All rights reserved.
Revised: November 25, 2006