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SECURE ON-LINE ORDER FORM
PRODUCT INFORMATION
PRICES INCLUDE SHIPPING & HANDLING
PLEASE FILL IN NECESSARY FIELDS BELOW
Item #
Description
Color
Price
each
Qty.
Line
Total
    Order Total  

SHIPPING INFORMATION

First Name:

Last Name:
Address:
City: State:
Zip:
Country:
Phone Number:
E-Mail Address:

PAYMENT INFORMATION
Name On Card:
Type Of Card:
Credit Card Number:
Expiration Date:
v code
The v code is a 3 digit number found on the back of VISA, MC & Discover in
the signature section and a 4 digit number on the front right of AMEX
Comments:

Lazy J Leather
6188 Gravel Hill Road | Phil Campbell, AL 35581
(Phone): 205:993-5232 | (Email): lazyjleather@msn.com
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