Please fill out and fax form to Richard's (503-590-7945)

I authorize you to charge my credit card

  [  ] Visa    [  ] Mastercard   [  ] American Express
  [  ] Diners Club   [  ] JCB (Japan Credit Bureau)
Number________________________ Exp. Date_________
Signature________________________________

 

First Name__________________  Last Name___________________
Address_________________________________________________
City_______________________________
State/Prov/Zip____________________________________
Country____________________________________________

 

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