SHIP TO:

Name: ______________________________

Address: ____________________________

Address: ____________________________

City: ___________________CA Zip________

For Shipping Within California Only. Must be ordered and received (proof of age required) by person 21 years old or older.

Please provide Convenient time for phone confirmation.

Phone: _________________________________

___________________________________________

Credit Card Information

Name: ___________________________________

Circle One: Master Card or Visa

Number: ________ ________ ________ ________

Expiration: _____________ Security Code: ______

Billing Address Zip Code: ___________