ChopStir Order Form

		Quantity
x	$5.49	Each
+	$2.75	Shipping
		Total

Please provide the following ordering information: 

	SHIPPING
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

Please provide us the following contact information:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

Please note that this is an unsecured form, your credit card will not be charged immediately. 
Please verify the charge on your next statement. Your credit card information will be 
removed as soon as the order is confirmed.

If you prefer you can print out this page and fax it to 719-536-9994.