| Your Name: | _______________________________________________ |
| Company: | _______________________________________________ (optional) |
| Street Address: | _______________________________________________ _______________________________________________ |
| City or Town: | _______________________ |
| State or Region: | _______________________ |
| Phone Numbers: Please include c area code |
Daytime: ________________ Evening: ________________ |
| Email address: Required for delivery |
_______________________________________________ |
| Credit Card Details | |
| Type of Card: Check one of these options |
[ ] VISA [ ] MasterCard [ ] AmericanExpress [ ] NOVUS/Discover |
| Credit Card Number: | ________________________________________ |
| Expiration Date: | Month: ____________ Year: ____________ |
| Amount: | $ ____________ . ___ U.S. Dollars |
| Cardholder's Name: | _______________________________________________ |
| Cardholder's Signature: | _______________________________________________ |
In order to avoid losing your info, If you have problems submitting your form, ( for example you get a message: "oops! must be a tripod website" ) after you receive the oops message, just click the "back" button and complete the missing information - if you still receive an oops message, you may want to just print the completed form and mail it to: xkr essex, inc. 2911 e. vista st. #C long beach, ca 90803