Order Information
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Funny collection: PipeFun, TetFun and ColorFun (3010-10) Price/Unit Quantity Total
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                                                         $24.90     _______  _____

TOTAL AMOUNT ($U.S.)		 	   		             _____________

Payment Information
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First Name:	__________________________________________________________________

Last Name:	__________________________________________________________________

Company:	__________________________________________________________________

Street Address: __________________________________________________________________

                __________________________________________________________________

City:		__________________________________________________________________

State/Province:  _________________________________________________________________

Zip/Postal Code:   _______________________________________________________________

Country: _________________________________________________________________________

Daytime Phone:    ________________________________________________________________

Fax: _____________________________________________________________________________

Email Address (required): ________________________________________________________

Payment:        __ MasterCard     __ VISA     __ AMEX     __ Discover

                __ Check       __ Money order       __ Purchase order

For credit card orders
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Name on Card: ____________________________________________________________________

Credit Card Number: ______________________________________________________________

Expiration Date: month ________________ year (4 digits) __________________________

                Signature : ___________________  Date: ___________________________