Name: ________________________________________

Shipping Address: _______________________________

                              _______________________________

                              _______________________________

Billing Address: ________________________________

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Phone #: ______________________________________

Card #: _______________________________________   

Exp Date: ________/_________

Verification Code: _______________

Approx. Ship Date: _____________________________

Order: ________________________________________

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Phone – 1-49-582-4321

Fax – 1-419-582-3013

E-Mail – winnersons@midohio.twcbc.com