E-Z PEDIGREE BASIC ORDER FORM
(For orders within the U.S. only)

CHAPMAN PET PROGRAMS
1951 Hwy 61
LORAINE, IL  62349
PH:(217) 696-2551
FAX:(217) 696-2802
E-MAIL: askme@ezkennel.com

You may print, complete and fax back,
mail or copy and paste information 
into an e-mail message to us.

E-Z PEDIGREE BASIC
PRICE:$58+$7(S&H)= $65.00


If installing on multiple PCs on a network
Add $25.00 for each additional Network Station.

NETWORK STATIONS:____ X $25.00=$_________

$65.00 + NETWORK STATIONS = TOTAL:$__________


FIRST NAME:
LAST NAME:
BUSINESS NAME:
ADDRESS:
CITY:
STATE:
ZIP:
PHONE:
FAX:
E-MAIL:
METHOD OF PAYMENT:
(We accept: Visa, Discover or MasterCard)
TYPE OF CARD:
CARD NUMBER:
EXP. DATE:
LAST 3 DIGITS OF NUMBER ON 
BACK OF CARD (IN SIGNATURE AREA):
NAME OF CARDHOLDER:
ADDRESS OF CARDHOLDER:
SIGNATURE(if faxing or mailing):