ORDER FORM
Please FILL OUT,
PRINT and MAIL to:
Dr. Michael Johnson
Rt. 1, Box 234
Idabel, OK 74745 USA
Telephone: 580-286-7784
Fax: 580-286-7476
Order Date: _______________________
PLEASE SHIP:
BILL TO: (select payment method)
Check
or money order
Please charge my credit card: (Please Provide
Credit Card Information Below)
| Credit
Card Type: |
|
Expiration: |
______________ |
| Credit
Card Number: |
_______________________________________________________________ |
| Card
Holder: |
_______________________________________________________________ |
|
(Name
as it appears on the credit card) |
|
Signature: |
___________________________________________________________ |
SHIP TO: Please provide your complete shipping address
below:
| Name: |
_______________________________________________________________ |
|
Address: |
_______________________________________________________________ |
|
City: |
_______________________________________________________________ |
|
State / Zip Code: |
_______________________________________________________________ |
| Phone: |
_______________________________________________________________ |
|