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	Online Order Form

ORDERING INSTRUCTIONS:

To Order Using Your CHARGE CARD:
We accept VISA, MasterCard, Discover and American Express.

Please type in the necessary and required information. When you have completed this, you may order using your charge card utilizing any one of the four following ways:

1) Submit your order electroncally by clicking on the "Send Order" button at the bottom of this page, or
2) Print all forms and MAIL to the address below, or
3) Print all forms and FAX or PHONE your order to: (208) 623-2400

(By submitting your order by any of the above methods, you authorize Lawicka to debit your credit card for the items ordered on this form).

Thank you for your order!


	Please enter your name and address as it is on file with your credit card company! We can not process your order unless we can verify your address with your credit card company. Fields marked with an * are REQUIRED to process your order.


	Name: *

Street Address, line 1: *

Street Address, line 2:

City: *

State / Province*

Country*

Zip / Postal Code: *


	Day Phone (area code and phone number): *

Evening Phone (area code and phone number): *

Method of Payment: *

Name as it appears on Card: *

Credit Card Number (xxxx-xxxx-xxxx-xxxx): *

Exp. Date (mm/yy): *

E-mail Address:

Information for First Person-(Birth Number 1)

Full Name as it appears on the birth certificate:

Maiden Name (if applicable):

Birth Date (mo/day/yr):

Birth Time (AM or PM) :

Note: If you don't know birth "time", we will use 12:01 PM Noon

Birth Place (City, State, Country):

Information for Second Person-(Birth Number 2)

Full Name as it appears on the birth certificate:

Maiden Name (if applicable):

Birth Date (mo/day/yr):

Birth Time (AM or PM):

Note: If you don't know birth "time", we will use 12:01 PM Noon

Birth Place (City, State, Country):


	$3 shipping and handling will be added per order. All prices are in US dollars. Comments (optional):



	WARNING! Credit card fraud is a felony and Lawicka will aggressively prosecute anyone attempting to misuse a credit card number. Lawicka tracks every transaction and will use all means available to it to prosecute persons attempting fraud. All reports are 100% SATISFACTION GUARANTEED! By clicking on the "Send Order" button below, I authorize Lawicka to debit my credit card for the items ordered on this form.







	695 Eagle Drive, Spirit Lake, ID 83869-9690 24 Hour Voice and Fax: (208) 623-2400 Email us at lawicka@lawicka.com © 1998-2000 Lawicka, All rights reserved.