-----------------------------------------------------------------------------

FAX this form to 1-419-754-2253

___ Enclosed is my check, money order or credit card order for $_____________.00
plus $7 S&H ($17 foreign orders)

Totaling $__________________.00

Charge my: Visa, MasterCard, American Express, Discover

Card Number:___________________________________________ Exp. Date:______________

Signature: __________________________________________

Print Name: ________________________________________________________________

Address 1: ________________________________________________________________

Address 2: ________________________________________________________________

City: ______________________________________ State: __________________________

Zip Code: ______________________________ Country: ___________________________

Date of Birth: _____________________________________

Telephone: _______________________________________________

Fax Number: _____________________________________________

E-Mail: __________________________________________________