Name: _________________________

Address: ____________________ City: ________________ State: ___ Zip: ____________

Phone: _____________ Fax: ____________ E-mail: _____________ Other: ____________

Card Name: Master Card ___ Visa ___

Account #: ________________________________________ Expiration Date ________

Cardholder Name: (print name) ____________________________

Signature:____________________________

Please Note: Your order will be processed by AIM Marketing Their name will appear onyour credit card billing statement for yhe amount of this purchase.
($15 fee will be charged for re-processing of charge backs)  

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1. Name: ____________________ Phone: _____________ Fax: ________________

2. Name: _________________________ Phone: _____________ Fax: ________________

3. Name: _________________________ Phone: _____________ Fax: ________________

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