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Name-------------------------------------Date--------------------

Billing Address--------------------------------------------------

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Day Phone---------------------     Home Phone--------------------

Shipping Address (If different than billing address)

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Payment Options: 
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I am sending this to you by mail.
Enclose Check or money order. 
MAIL TO: 
Client Media Consultants
Post Office Box 13583
Chandler, AZ 85248 I am faxing you this order Bill my MasterCard or Visa FAX TO: 480-290-7867 Card Number-------------------------------------- Name On Card------------------------------------- Expiration Date--------------------------------- Please ship me the following items Quantity Item Price With Shipping ---------------------------------------------------------------- ---------------------------------------------------------------- ---------------------------------------------------------------- ----------------------------------------------------------------- SUB TOTAL $---------- Arizona RESIDENTS ADD 7.3% Sales Tax $---------- TOTAL $----------