Payment Information:

 Personal Check/Money Order Enclosed payable to "Brinda Devine" ($US funds)
 Charge my Credit Card:   Visa    MasterCard   
                                     American Express   Discover
Card Number: _______________________________________________
Expiration Date: (MM/YY) ___ /___   Card Verification Number*_________

*With MasterCard or Visa there is a number printed on the signature strip on the back of the credit card. The card verification number follows the credit card number. It is the last three digits of it. On Amex cards, the number is on the front of the card.

Name on card: _______________________________________________

Sold to:
Name: _____________________________________________________
Street Address: _____________________________________________
City: _________________________   State: _______   Zip: _________
Telephone: _____________________ Fax: _____________________
E-mail: __________________________________________________
Ship to: (if different from above)
Name: ______________________________________________________
Street Address: ______________________________________________
City: _________________________   State: _______   Zip: __________