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- <p><br /><br /><br /></p>
- <div><br /><br /><br />
- <div><br /><br /> 1. Contact Information<br /><br /></div>
- <br /><br /><br /><br /> Name<span>*</span><br /><br />
- <div><span><br /> First Name </span><span><br /> Last Name </span></div>
- <br /><br /><br /><br /> E-mail<span>*</span><br /><br />
- <div><br /><br /></div>
- <br /><br /><br />
- <div><br /><br /> 2. Select Your Product<br /><br /></div>
- <br /><br /><br /><br /> Style Hat:<span>*</span><br /><br />
- <div><br />
- <div><span style="clear: left;"><br /> Classic Solid Snapback </span><span> </span><span style="clear: left;"><br /> Classic Two Tone Snapback </span><span> </span><span style="clear: left;"><br /> Specialty Snapbacks </span><span> </span><span style="clear: left;"><br /> 5 Panel Snapback </span><span> </span><span style="clear: left;"><br /> 5 Panel Jockey Cap </span><span> </span><span style="clear: left;"><br /> Premium Flexfit Fitted </span><span> </span><span style="clear: left;"><br /> Classic Beanie </span><span style="clear: left;"><br /> Classic Pom Pom Beanie </span></div>
- </div>
- <br /><br /><br />
- <div><br />
- <div><br /><br /><strong><br /> Classic Solid Snapback<br /></strong><br /><br />
- <div><br />
- <p><br /><img src="http://www.formstack.com/forms/images/user/375551/image_solidblack.jpg" alt="solidblack.jpg" width="259" height="160" /></p>
- <br />
- <table>
- <tbody>
- <tr>
- <td><br /><strong><br /> QTY<br /></strong><br /></td>
- <td><br /><strong><br /> Front<br /></strong><br /></td>
- <td><br /><strong><br /> Side<br /></strong><br /></td>
- <td><br /><strong><br /> Back<br /></strong><br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 12<br /></strong><br /></td>
- <td><br /> $24<br /></td>
- <td><br /> N/A<br /></td>
- <td><br /> N/A<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 24<br /></strong><br /></td>
- <td><br /> $19<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 48<br /></strong><br /></td>
- <td><br /> $16<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 72<br /></strong><br /></td>
- <td><br /> $14<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 144<br /></strong><br /></td>
- <td><br /> $12<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- </tbody>
- </table>
- <br />
- <p><br /><br /><br /><br /><br /> New Era= +$3.00 per hat<br /><br /><br /> Minimum 12 hats per color</p>
- </div>
- </div>
- </div>
- <br /><br /><br /><br /> Choose Color<span>*</span><br /><br />
- <div><br /><br /><br /> Black (New Era) <br /> White (New Era) <br /> Deep Navy (New Era) <br /> Stone (New Era) <br /> Purple (New Era) <br /> Heather Grey <br /> Black (pictured) <br /> Navy <br /> Cardinal <br /> Kelly Green <br /> Red <br /> Royal <br /> Maroon <br /> Orange <br /> Grey <br /> White <br /> Purple <br /> Charcoal <br /><br /></div>
- <br /><br /><br />
- <div><br />
- <div><br />
- <table>
- <tbody>
- <tr>
- <td><br /><br /><strong><br /> Classic Two Tone Snapback<br /></strong><br /><br />
- <div><br />
- <p><br /><img src="http://www.formstack.com/forms/images/user/375551/image_blackred.jpg" alt="blackred.jpg" width="259" height="160" /></p>
- <br />
- <table>
- <tbody>
- <tr>
- <td><br /><strong><br /> QTY<br /></strong><br /></td>
- <td><br /><strong><br /> Front<br /></strong><br /></td>
- <td><br /><strong><br /> Side<br /></strong><br /></td>
- <td><br /><strong><br /> Back<br /></strong><br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 12<br /></strong><br /></td>
- <td><br /> $24<br /></td>
- <td><br /> N/A<br /></td>
- <td><br /> N/A<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 24<br /></strong><br /></td>
- <td><br /> $19<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 48<br /></strong><br /></td>
- <td><br /> $16<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 72<br /></strong><br /></td>
- <td><br /> $14<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 144<br /></strong><br /></td>
- <td><br /> $12<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- </tbody>
- </table>
- </div>
- <br /></td>
- </tr>
- </tbody>
- </table>
- </div>
- </div>
- <br /><br /><br /><br /> Choose Color:<span>*</span><br /><br />
- <div><br /><br /><br /> Black / Cardinal <br /> Black / Grey <br /> Black / Gold <br /> Black / Orange <br /> Black / Purple <br /> Black / Pink <br /> Black / Navy <br /> Black / Neon Green <br /> Black / Teal <br /> Charcoal / Black <br /> Cardinal / Black <br /> Grey / Black <br /> Grey / Navy <br /> Grey / Royal <br /> Kelly / Black <br /> Kelly / Red <br /> Navy / Black <br /> Navy / Grey <br /> Navy / Red <br /> Red / Black <br /> Red / Kelly <br /> Red / Navy <br /> Royal / White <br /> Purple / Gold (Lakers) <br /> Royal / Orange (Knicks) <br /> White / Black <br /><br /></div>
- <br /><br /><br />
- <div><br />
- <div><br />
- <table>
- <tbody>
- <tr>
- <td><br /><br /><strong><br /> Specialty Snapbacks<br /></strong><br /><br /><img src="http://www.formstack.com/forms/images/user/375551/image_special.jpg" alt="" width="259" height="160" /><br />
- <div><br />
- <table>
- <tbody>
- <tr>
- <td><br /><strong><br /> QTY<br /></strong><br /></td>
- <td><br /><strong><br /> Front<br /></strong><br /></td>
- <td><br /><strong><br /> Side<br /></strong><br /></td>
- <td><br /><strong><br /> Back<br /></strong><br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 12<br /></strong><br /></td>
- <td><br /> $26<br /></td>
- <td><br /> N/A<br /></td>
- <td><br /> N/A<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 24<br /></strong><br /></td>
- <td><br /> $21<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 48<br /></strong><br /></td>
- <td><br /> $18<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 72<br /></strong><br /></td>
- <td><br /> $16<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 144<br /></strong><br /></td>
- <td><br /> $14<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- </tbody>
- </table>
- </div>
- <br /></td>
- </tr>
- </tbody>
- </table>
- </div>
- </div>
- <br /><br /><br /><br /> Choose Color:<span>*</span><br /><br />
- <div><br /><br /><br /> Full Camo <br /> White / Camo <br /> Camo / Black <br /> White / Aztec <br /> Red / Aztec <br /> Black / Aztec <br /> Black / Snakeskin <br /> White / Skakeskin <br /> Black / Leopard <br /> Black / Zebra <br /><br /></div>
- <br /><br /><br />
- <div><br />
- <div><br />
- <table>
- <tbody>
- <tr>
- <td><br /><br /><strong><br /> 5 Panel Snapback<br /></strong><br /><br />
- <div><br />
- <p><br /><img src="http://www.formstack.com/forms/images/user/375551/image_5panel.jpg" alt="5panel.jpg" width="259" height="160" /></p>
- <br />
- <table>
- <tbody>
- <tr>
- <td><br /><strong><br /> QTY<br /></strong><br /></td>
- <td><br /><strong><br /> Front<br /></strong><br /></td>
- <td><br /><strong><br /> Side<br /></strong><br /></td>
- <td><br /><strong><br /> Back<br /></strong><br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 12<br /></strong><br /></td>
- <td><br /> $25<br /></td>
- <td><br /> N/A<br /></td>
- <td><br /> N/A<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 24<br /></strong><br /></td>
- <td><br /> $20<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 48<br /></strong><br /></td>
- <td><br /> $17<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 72<br /></strong><br /></td>
- <td><br /> $15<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 144<br /></strong><br /></td>
- <td><br /> $13<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- </tbody>
- </table>
- </div>
- <br /></td>
- </tr>
- </tbody>
- </table>
- </div>
- </div>
- <br /><br /><br /><br /> Choose Color:<span>*</span><br /><br />
- <div><br /><br /><br /> Black <br /> Red <br /> Grey <br /> Navy <br /> Royal <br /> White <br /> Black / Red <br /> Black / Silver (pictured) <br /> Navy / Red <br /><br /></div>
- <br /><br /><br />
- <div><br />
- <div><br />
- <table>
- <tbody>
- <tr>
- <td><br /><br /><strong><br /> 5 Panel Jockey Cap<br /></strong><br /><br />
- <div><br />
- <p><br /><img src="http://www.formstack.com/forms/images/user/375551/image_jockey.jpg" alt="jockey.jpg" width="259" height="160" /></p>
- <br />
- <table>
- <tbody>
- <tr>
- <td><br /><strong><br /> QTY<br /></strong><br /></td>
- <td><br /><strong><br /> Front<br /></strong><br /></td>
- <td><br /><strong><br /> Side<br /></strong><br /></td>
- <td><br /><strong><br /> Back<br /></strong><br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 12<br /></strong><br /></td>
- <td><br /> $25<br /></td>
- <td><br /> N/A<br /></td>
- <td><br /> N/A<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 24<br /></strong><br /></td>
- <td><br /> $20<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 48<br /></strong><br /></td>
- <td><br /> $17<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 72<br /></strong><br /></td>
- <td><br /> $15<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 144<br /></strong><br /></td>
- <td><br /> $13<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- </tbody>
- </table>
- </div>
- <br /></td>
- </tr>
- </tbody>
- </table>
- </div>
- </div>
- <br /><br /><br /><br /> Choose Color:<span>*</span><br /><br />
- <div><br /><br /><br /> Navy (pictured) <br /> Black <br /> Grey <br /> Olive <br /> Khaki <br /> Red <br /> Navy <br /><br /></div>
- <br /><br /><br />
- <div><br />
- <div><br />
- <table>
- <tbody>
- <tr>
- <td><br /><br /><strong><br /> Premium Flexfit Fitted<br /></strong><br /><br />
- <div><br />
- <p><br /><img src="http://www.formstack.com/forms/images/user/375551/image_fittedflex.jpg" alt="fittedflex.jpg" width="259" height="160" /></p>
- <br />
- <table>
- <tbody>
- <tr>
- <td><br /><strong><br /> QTY<br /></strong><br /></td>
- <td><br /><strong><br /> Front<br /></strong><br /></td>
- <td><br /><strong><br /> Side<br /></strong><br /></td>
- <td><br /><strong><br /> Back<br /></strong><br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 12<br /></strong><br /></td>
- <td><br /> $26<br /></td>
- <td><br /> N/A<br /></td>
- <td><br /> N/A<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 24<br /></strong><br /></td>
- <td><br /> $21<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 48<br /></strong><br /></td>
- <td><br /> $17<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 72<br /></strong><br /></td>
- <td><br /> $15<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 144<br /></strong><br /></td>
- <td><br /> $13<br /></td>
- <td><br /> Free<br /></td>
- <td><br /> +$2<br /></td>
- </tr>
- </tbody>
- </table>
- </div>
- <br /></td>
- </tr>
- </tbody>
- </table>
- </div>
- </div>
- <br /><br /><br /><br /> Choose Color:<span>*</span><br /><br />
- <div><br /><br /><br /> Black <br /> Red <br /> Brown <br /> Navy <br /> Heather Grey (pictured) <br /> Royal <br /> White <br /> Dark Grey <br /> Black / Purple <br /> Black / Grey <br /> Black / Red <br /> Red / Black <br /> White / Black <br /><br /></div>
- <br /><br /><br />
- <div><br />
- <div><br />
- <table>
- <tbody>
- <tr>
- <td><br /><br /><strong><br /> Classic Beanie<br /></strong><br /><br />
- <div><br />
- <p><br /><img src="http://www.formstack.com/forms/images/user/375551/image_custombeanie.jpg" alt="custombeanie.jpg" width="259" height="160" /></p>
- <br />
- <table>
- <tbody>
- <tr>
- <td><br /><strong><br /> QTY<br /></strong><br /></td>
- <td><br /><strong><br /> Price<br /></strong><br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 12<br /></strong><br /></td>
- <td><br /> $22<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 24<br /></strong><br /></td>
- <td><br /> $17<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 48<br /></strong><br /></td>
- <td><br /> $14<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 72<br /></strong><br /></td>
- <td><br /> $12<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 144<br /></strong><br /></td>
- <td><br /> $10<br /></td>
- </tr>
- </tbody>
- </table>
- </div>
- <br /></td>
- </tr>
- </tbody>
- </table>
- </div>
- </div>
- <br /><br /><br /><br /> Choose Color:<span>*</span><br /><br />
- <div><br /><br /><br /> Black <br /> Red <br /> Brown <br /> Navy <br /> Grey <br /> Royal <br /> White <br /> Pink <br /> Carolina Blue <br /> Safety Green <br /> Kelly <br /> Purple <br /> Orange (pictured) <br /> Royal / Grey <br /> Red / Black <br /> Black / Red <br /> Black / Kelly <br /> Black / Purple <br /> Black / Grey <br /> Black / Orange <br /><br /></div>
- <br /><br /><br />
- <div><br />
- <div><br />
- <table>
- <tbody>
- <tr>
- <td><br /><br /><strong><br /> Classic Pom Pom Beanie<br /></strong><br /><br />
- <div><br />
- <p><br /><img src="http://www.formstack.com/forms/images/user/375551/image_pombeanie.jpg" alt="pombeanie.jpg" width="259" height="160" /></p>
- <br />
- <table>
- <tbody>
- <tr>
- <td><br /><strong><br /> QTY<br /></strong><br /></td>
- <td><br /><strong><br /> Price<br /></strong><br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 12<br /></strong><br /></td>
- <td><br /> $22<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 24<br /></strong><br /></td>
- <td><br /> $17<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 48<br /></strong><br /></td>
- <td><br /> $14<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 72<br /></strong><br /></td>
- <td><br /> $12<br /></td>
- </tr>
- <tr>
- <td><br /><strong><br /> 144<br /></strong><br /></td>
- <td><br /> $10<br /></td>
- </tr>
- </tbody>
- </table>
- </div>
- <br /></td>
- </tr>
- </tbody>
- </table>
- </div>
- </div>
- <br /><br /><br /><br /> Choose Color:<span>*</span><br /><br />
- <div><br /><br /><br /> Green / Black <br /> Black / Gold <br /> Green / Yellow <br /><br /></div>
- <br /><br /><br />
- <div><br /><br /> 3. Choose Quantity<br /><br /></div>
- <br /><br /><br /><br /> How many hats would you like?<span>*</span><br /><br />
- <div><span><br /> Minimum of 12 </span></div>
- <br /><br /><br />
- <div><br /><br /> 4. Customize Your Hats<br /><br /></div>
- <br /><br /><br />
- <div><br />
- <div><br /><img src="http://www.formstack.com/forms/images/user/375551/image_locations.jpg" alt="locations.jpg" /><br />
- <p><br /> *Orders under 24 pieces can only have 1 location.</p>
- </div>
- </div>
- <br /><br /><br /><br /> Choose Locations<span>*</span><br /><br />
- <div><br />
- <div><span style="clear: left;"><br /> Front </span><span style="clear: left;"><br /> Side </span><span style="clear: left;"><br /> Back </span></div>
- </div>
- <br /><br /><br /><br />
- <div><span>Front</span><span> </span></div>
- <br /><br /><br />
- <div><br />
- <div><br />
- <p><br /><img src="http://www.jotform.com/uploads/pinoytech/form_files/shadow.png" alt="" width="630" height="20" /></p>
- <br />
- <p><span style="font-size: medium;"><strong><br /> Front Location<br /></strong></span></p>
- </div>
- </div>
- <br /><br /><br /> Upload Your Artwork <br />
- <div><br /><br /></div>
- <br /><br /><br /> Instructions For Embroidery <br />
- <div><span><br /><br /> Describe your artwork in detail and our skilled graphic designers will create a virtual mock up and send it to you for approval.<br /><br /><br /> All for Free!<br /></span></div>
- <br /><br /><br /><br /><br />
- <div><span>Side</span><span> </span></div>
- <br /><br /><br />
- <div><br />
- <div><br />
- <p><br /><img src="http://www.jotform.com/uploads/pinoytech/form_files/shadow.png" alt="" width="630" height="20" /></p>
- <br />
- <p><span style="font-size: medium;"><strong><br /> Side Location<br /></strong></span></p>
- </div>
- </div>
- <br /><br /><br /> Upload Your Artwork <br />
- <div><br /><br /></div>
- <br /><br /><br /> Instructions For Embroidery <br />
- <div><span><br /><br /> Describe your artwork in detail and our skilled graphic designers will create a virtual mock up and send it to you for approval.<br /><br /><br /> All for Free!<br /></span></div>
- <br /><br /><br /><br /><br />
- <div><span>Back</span><span> </span></div>
- <br /><br /><br />
- <div><br />
- <div><br />
- <p><br /><img src="http://www.jotform.com/uploads/pinoytech/form_files/shadow.png" alt="" width="630" height="20" /></p>
- <br />
- <p><span style="font-size: medium;"><strong><br /> Back Location<br /></strong></span></p>
- </div>
- </div>
- <br /><br /><br /> Upload Your Artwork <br />
- <div><br /><br /></div>
- <br /><br /><br /> Instructions For Embroidery <br />
- <div><span><br /><br /> Describe your artwork in detail and our skilled graphic designers will create a virtual mock up and send it to you for approval.<br /><br /><br /> All for Free!<br /></span></div>
- <br /><br /><br /><br /><br />
- <div><span>Submit</span><span> </span></div>
- <br /><br /><br />
- <div><br /><br /> 5. Ready for a quote?<br /><br /></div>
- <br /><br /><br /> How did you hear about us? <br />
- <div><br /><br /><br /> Google <br /> Yahoo <br /> Bing <br /> Facebook <br /> Twitter <br /> Friend <br /> Advertisemet <br /><br /></div>
- <br /><br /><br /><br /> I understand the companies terms & conditions<span>*</span><br /><br />
- <div><br />
- <div><span style="clear: left;"><br /> Yes, send me my quote! </span></div>
- </div>
- <br /><br /><br />
- <div><br />
- <div><br /><br /><strong><br /> 6. Submit your order form<br /></strong><br /><br />
- <div><br />
- <p><br /><strong><br /> 100% Risk Free - Order Your Custom Snapback Today<br /></strong></p>
- <br />
- <p><br /> Due to an <br /><em><br /> overwhelming<br /></em><br /> amount of submissions, we are now requesting a Refundable $15 No Risk Deposit on all new orders.</p>
- <br />
- <p><br /> This is the only way to deal with the number of submissions while focusing on our more serious clients.</p>
- <br />
- <p><br /> This deposit is 100% refundable and will be deducted from your order. If you would not like to proceed, simply request a refund. We retain the right to keep the deposit if a refund is not requested within 3 months.</p>
- <br />
- <p><br /> Once received our professional graphic designers will work closely with you to achieve the perfect design for your hats.</p>
- <br />
- <p><br /> No orders are processed until client gives final art approval.</p>
- </div>
- </div>
- </div>
- <br /><br /><br /><br /> Risk Free Deposit<span>*</span><br /><br />
- <div><br /><span><br /><br /> 100% Refundable Deposit<span><strong><br /> $<span>15.00</span><br /> USD<br /></strong></span><br /></span><br /><br /><br /><br />
- <table>
- <tbody>
- <tr>
- <td><br /><br /><br />
- <div><br /><img src="http://cdn.jotfor.ms/images/blank.gif" alt="blank.gif" /><br /><img src="http://cdn.jotfor.ms/images/blank.gif" alt="blank.gif" /><br /><img src="http://cdn.jotfor.ms/images/blank.gif" alt="blank.gif" /><br /><img src="http://cdn.jotfor.ms/images/blank.gif" alt="blank.gif" /></div>
- <br /><br /></td>
- <td><br /><br /> <img src="http://cdn.jotfor.ms/images/paypal_logo.png" alt="paypal_logo.png" /><br /></td>
- </tr>
- </tbody>
- </table>
- <br />
- <table>
- <tbody>
- <tr>
- <td><span><br /> First Name </span><br /></td>
- <td><span><br /> Last Name </span><br /></td>
- </tr>
- </tbody>
- </table>
- <span><br /> -<br /> Credit Card Number </span><span><br /> Security Code </span><br /><br /><br /><br /><span><br /><br /> January <br /> February <br /> March <br /> April <br /> May <br /> June <br /> July <br /> August <br /> September <br /> October <br /> November <br /> December <br /><br /> /<br /> Expiration Month </span><span><br /><br /> 2013 <br /> 2014 <br /> 2015 <br /> 2016 <br /> 2017 <br /> 2018 <br /> 2019 <br /> 2020 <br /> 2021 <br /> 2022 <br /><br /> Expiration Year </span><br /><br /><br /><br /><br /> Billing Address<br /><br /><br /><br /><span><br /> Street Address </span><br /><br /><br /><br /><span><br /> Street Address Line 2 </span><br /><br /><br /><br /><span><br /> City </span><br /><br /><span><br /> State / Province </span><br /><br /><br /><br /><span><br /> Postal / Zip Code </span><br /><br /><span><br /> Please Select <br /> United States <br /> Afghanistan <br /> Albania <br /> Algeria <br /> American Samoa <br /> Andorra <br /> Angola <br /> Anguilla <br /> Antigua and Barbuda <br /> Argentina <br /> Armenia <br /> Aruba <br /> Australia <br /> Austria <br /> Azerbaijan <br /> The Bahamas <br /> Bahrain <br /> Bangladesh <br /> Barbados <br /> Belarus <br /> Belgium <br /> Belize <br /> Benin <br /> Bermuda <br /> Bhutan <br /> Bolivia <br /> Bosnia and Herzegovina <br /> Botswana <br /> Brazil <br /> Brunei <br /> Bulgaria <br /> Burkina Faso <br /> Burundi <br /> Cambodia <br /> Cameroon <br /> Canada <br /> Cape Verde <br /> Cayman Islands <br /> Central African Republic <br /> Chad <br /> Chile <br /> People's Republic of China <br /> Republic of China <br /> Christmas Island <br /> Cocos (Keeling) Islands <br /> Colombia <br /> Comoros <br /> Congo <br /> Cook Islands <br /> Costa Rica <br /> Cote d'Ivoire <br /> Croatia <br /> Cuba <br /> Cyprus <br /> Czech Republic <br /> Denmark <br /> Djibouti <br /> Dominica <br /> Dominican Republic <br /> Ecuador <br /> Egypt <br /> El Salvador <br /> Equatorial Guinea <br /> Eritrea <br /> Estonia <br /> Ethiopia <br /> Falkland Islands <br /> Faroe Islands <br /> Fiji <br /> Finland <br /> France <br /> French Polynesia <br /> Gabon <br /> The Gambia <br /> Georgia <br /> Germany <br /> Ghana <br /> Gibraltar <br /> Greece <br /> Greenland <br /> Grenada <br /> Guadeloupe <br /> Guam <br /> Guatemala <br /> Guernsey <br /> Guinea <br /> Guinea-Bissau <br /> Guyana <br /> Haiti <br /> Honduras <br /> Hong Kong <br /> Hungary <br /> Iceland <br /> India <br /> Indonesia <br /> Iran <br /> Iraq <br /> Ireland <br /> Israel <br /> Italy <br /> Jamaica <br /> Japan <br /> Jersey <br /> Jordan <br /> Kazakhstan <br /> Kenya <br /> Kiribati <br /> North Korea <br /> South Korea <br /> Kosovo <br /> Kuwait <br /> Kyrgyzstan <br /> Laos <br /> Latvia <br /> Lebanon <br /> Lesotho <br /> Liberia <br /> Libya <br /> Liechtenstein <br /> Lithuania <br /> Luxembourg <br /> Macau <br /> Macedonia <br /> Madagascar <br /> Malawi <br /> Malaysia <br /> Maldives <br /> Mali <br /> Malta <br /> Marshall Islands <br /> Martinique <br /> Mauritania <br /> Mauritius <br /> Mayotte <br /> Mexico <br /> Micronesia <br /> Moldova <br /> Monaco <br /> Mongolia <br /> Montenegro <br /> Montserrat <br /> Morocco <br /> Mozambique <br /> Myanmar <br /> Nagorno-Karabakh <br /> Namibia <br /> Nauru <br /> Nepal <br /> Netherlands <br /> Netherlands Antilles <br /> New Caledonia <br /> New Zealand <br /> Nicaragua <br /> Niger <br /> Nigeria <br /> Niue <br /> Norfolk Island <br /> Turkish Republic of Northern Cyprus <br /> Northern Mariana <br /> Norway <br /> Oman <br /> Pakistan <br /> Palau <br /> Palestine <br /> Panama <br /> Papua New Guinea <br /> Paraguay <br /> Peru <br /> Philippines <br /> Pitcairn Islands <br /> Poland <br /> Portugal <br /> Puerto Rico <br /> Qatar <br /> Romania <br /> Russia <br /> Rwanda <br /> Saint Barthelemy <br /> Saint Helena <br /> Saint Kitts and Nevis <br /> Saint Lucia <br /> Saint Martin <br /> Saint Pierre and Miquelon <br /> Saint Vincent and the Grenadines <br /> Samoa <br /> San Marino <br /> Sao Tome and Principe <br /> Saudi Arabia <br /> Senegal <br /> Serbia <br /> Seychelles <br /> Sierra Leone <br /> Singapore <br /> Slovakia <br /> Slovenia <br /> Solomon Islands <br /> Somalia <br /> Somaliland <br /> South Africa <br /> South Ossetia <br /> Spain <br /> Sri Lanka <br /> Sudan <br /> Suriname <br /> Svalbard <br /> Swaziland <br /> Sweden <br /> Switzerland <br /> Syria <br /> Taiwan <br /> Tajikistan <br /> Tanzania <br /> Thailand <br /> Timor-Leste <br /> Togo <br /> Tokelau <br /> Tonga <br /> Transnistria Pridnestrovie <br /> Trinidad and Tobago <br /> Tristan da Cunha <br /> Tunisia <br /> Turkey <br /> Turkmenistan <br /> Turks and Caicos Islands <br /> Tuvalu <br /> Uganda <br /> Ukraine <br /> United Arab Emirates <br /> United Kingdom <br /> Uruguay <br /> Uzbekistan <br /> Vanuatu <br /> Vatican City <br /> Venezuela <br /> Vietnam <br /> British Virgin Islands <br /> US Virgin Islands <br /> Wallis and Futuna <br /> Western Sahara <br /> Yemen <br /> Zambia <br /> Zimbabwe <br /> Other <br /><br /> Country </span><br /><br /><br /><br /></div>
- <br /><br /><br /> Shipping address is different from billing <br />
- <div><br />
- <div><span style="clear: left;"><br /> Yes </span></div>
- </div>
- <br /><br /><br /> Shipping Address: <br />
- <div><br />
- <table>
- <tbody>
- <tr>
- <td><span><br /> Street Address </span><br /></td>
- </tr>
- <tr>
- <td><span><br /> Street Address Line 2 </span><br /></td>
- </tr>
- <tr>
- <td><span><br /> City </span><br /></td>
- <td><span><br /> State / Province </span><br /></td>
- </tr>
- <tr>
- <td><span><br /> Postal / Zip Code </span><br /></td>
- <td><span><br /> Please Select <br /> United States <br /> Afghanistan <br /> Albania <br /> Algeria <br /> American Samoa <br /> Andorra <br /> Angola <br /> Anguilla <br /> Antigua and Barbuda <br /> Argentina <br /> Armenia <br /> Aruba <br /> Australia <br /> Austria <br /> Azerbaijan <br /> The Bahamas <br /> Bahrain <br /> Bangladesh <br /> Barbados <br /> Belarus <br /> Belgium <br /> Belize <br /> Benin <br /> Bermuda <br /> Bhutan <br /> Bolivia <br /> Bosnia and Herzegovina <br /> Botswana <br /> Brazil <br /> Brunei <br /> Bulgaria <br /> Burkina Faso <br /> Burundi <br /> Cambodia <br /> Cameroon <br /> Canada <br /> Cape Verde <br /> Cayman Islands <br /> Central African Republic <br /> Chad <br /> Chile <br /> People's Republic of China <br /> Republic of China <br /> Christmas Island <br /> Cocos (Keeling) Islands <br /> Colombia <br /> Comoros <br /> Congo <br /> Cook Islands <br /> Costa Rica <br /> Cote d'Ivoire <br /> Croatia <br /> Cuba <br /> Cyprus <br /> Czech Republic <br /> Denmark <br /> Djibouti <br /> Dominica <br /> Dominican Republic <br /> Ecuador <br /> Egypt <br /> El Salvador <br /> Equatorial Guinea <br /> Eritrea <br /> Estonia <br /> Ethiopia <br /> Falkland Islands <br /> Faroe Islands <br /> Fiji <br /> Finland <br /> France <br /> French Polynesia <br /> Gabon <br /> The Gambia <br /> Georgia <br /> Germany <br /> Ghana <br /> Gibraltar <br /> Greece <br /> Greenland <br /> Grenada <br /> Guadeloupe <br /> Guam <br /> Guatemala <br /> Guernsey <br /> Guinea <br /> Guinea-Bissau <br /> Guyana <br /> Haiti <br /> Honduras <br /> Hong Kong <br /> Hungary <br /> Iceland <br /> India <br /> Indonesia <br /> Iran <br /> Iraq <br /> Ireland <br /> Israel <br /> Italy <br /> Jamaica <br /> Japan <br /> Jersey <br /> Jordan <br /> Kazakhstan <br /> Kenya <br /> Kiribati <br /> North Korea <br /> South Korea <br /> Kosovo <br /> Kuwait <br /> Kyrgyzstan <br /> Laos <br /> Latvia <br /> Lebanon <br /> Lesotho <br /> Liberia <br /> Libya <br /> Liechtenstein <br /> Lithuania <br /> Luxembourg <br /> Macau <br /> Macedonia <br /> Madagascar <br /> Malawi <br /> Malaysia <br /> Maldives <br /> Mali <br /> Malta <br /> Marshall Islands <br /> Martinique <br /> Mauritania <br /> Mauritius <br /> Mayotte <br /> Mexico <br /> Micronesia <br /> Moldova <br /> Monaco <br /> Mongolia <br /> Montenegro <br /> Montserrat <br /> Morocco <br /> Mozambique <br /> Myanmar <br /> Nagorno-Karabakh <br /> Namibia <br /> Nauru <br /> Nepal <br /> Netherlands <br /> Netherlands Antilles <br /> New Caledonia <br /> New Zealand <br /> Nicaragua <br /> Niger <br /> Nigeria <br /> Niue <br /> Norfolk Island <br /> Turkish Republic of Northern Cyprus <br /> Northern Mariana <br /> Norway <br /> Oman <br /> Pakistan <br /> Palau <br /> Palestine <br /> Panama <br /> Papua New Guinea <br /> Paraguay <br /> Peru <br /> Philippines <br /> Pitcairn Islands <br /> Poland <br /> Portugal <br /> Puerto Rico <br /> Qatar <br /> Romania <br /> Russia <br /> Rwanda <br /> Saint Barthelemy <br /> Saint Helena <br /> Saint Kitts and Nevis <br /> Saint Lucia <br /> Saint Martin <br /> Saint Pierre and Miquelon <br /> Saint Vincent and the Grenadines <br /> Samoa <br /> San Marino <br /> Sao Tome and Principe <br /> Saudi Arabia <br /> Senegal <br /> Serbia <br /> Seychelles <br /> Sierra Leone <br /> Singapore <br /> Slovakia <br /> Slovenia <br /> Solomon Islands <br /> Somalia <br /> Somaliland <br /> South Africa <br /> South Ossetia <br /> Spain <br /> Sri Lanka <br /> Sudan <br /> Suriname <br /> Svalbard <br /> Swaziland <br /> Sweden <br /> Switzerland <br /> Syria <br /> Taiwan <br /> Tajikistan <br /> Tanzania <br /> Thailand <br /> Timor-Leste <br /> Togo <br /> Tokelau <br /> Tonga <br /> Transnistria Pridnestrovie <br /> Trinidad and Tobago <br /> Tristan da Cunha <br /> Tunisia <br /> Turkey <br /> Turkmenistan <br /> Turks and Caicos Islands <br /> Tuvalu <br /> Uganda <br /> Ukraine <br /> United Arab Emirates <br /> United Kingdom <br /> Uruguay <br /> Uzbekistan <br /> Vanuatu <br /> Vatican City <br /> Venezuela <br /> Vietnam <br /> British Virgin Islands <br /> US Virgin Islands <br /> Wallis and Futuna <br /> Western Sahara <br /> Yemen <br /> Zambia <br /> Zimbabwe <br /> Other <br /><br /> Country </span><br /></td>
- </tr>
- </tbody>
- </table>
- </div>
- <br /><br /><br />
- <div><br />
- <div><br />
- <p><br /><img src="http://www.formstack.com/forms/images/user/375551/image_formstack.jpg" alt="formstack.jpg" /></p>
- </div>
- </div>
- <br /><br /><br />
- <div><br />
- <div><br /><br /> Submit<br /><br /></div>
- </div>
- <br /><br /><br /> Should be Empty:<br /><br /><br /><br /></div>
- <p><br /><br /><br /></p>
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