Name

Phone Number

Address (street number and apt. number) (city, state, zip code)

E-mail

Receiver's Name (if different from above)

Mailing address (if different from above)

I want to buy

Model
	A735	A763	A765	Fanny Bag	Shoulder Bag	Wallet
Color
Quantity

I will pay by my credit card. Credit card No. is , expires (month)/(year)

Bill me; my address is , (if different from above)