<% 'Generate Credit Card List Do While NOT RSCC.EOF ccOption = ccOption & vbCrLf & "" RSCC.MoveNext Loop %> <% 'Generate State List Do While NOT RSState.EOF stateOption = stateOption & vbCrLf & "" RSState.MoveNext Loop %> <% 'Generate Country List Do While NOT RSCountry.EOF countryOption = countryOption & vbCrLf & "" RSCountry.MoveNext Loop %>
<% If SubscribeMail = "1" Then %> <% Else %> <% End If %>

1<%Else %>0<% End If %>"> PAYMENT INFORMATION

COMPLETE THIS SECTION FOR ELECTRONIC CHECK PURCHASES
Account Name:    ( Required ) Check Number:     
( Required )    
Street Address:    ( Required )  
Apt. or Suite:    ( Required )  
City:    ( Required )
State/Province:    ( Required )
Country:    ( Required )
Zip: 
Pay To: 
Amount: <%=FormatCurrency(GrandTotal)%>
Bank Name:    Payment Authorized by Account Holder
Indemnification Agreement Provided by Depositor.
Electronically Signed By:
Memo: 
 
Bank Routing Number:   ( Required ) Checking Account Number:   ( Required )

PURCHASER INFORMATION

Company:
Telephone: ( Required )
Fax:
E-Mail: ( Required )
Add to Mailing List:
SHIPPING INFORMATION

Name:

Company:

Address:

Apt. or Suite:

City:

State:

Country
Zip
Telephone:

SPECIAL INSTRUCTIONS