| Date:_____/_____/_____ | Payment Type: (check) (money order) | Name: _____________________________ Phone: (______)______________________ Email: ______________________________ | Please Make Check/Money Order Payable to: Affordable Security |
| Billing Address: | Shipping Address: |
| _________________________ | _________________________ |
| _________________________ | _________________________ |
| _________________________ | _________________________ |
| _________________________ | _________________________ |
Sub Total | ||
Ohio Residents: Please Add 7.50% Tax |
||
TOTAL |