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Name:______________________________________________________________
Email Address:_______________________________________________________
Address:_____________________________________________ (Please, no P.O Box #
City:_________________________    State:________      Zip Code:____________
Daytime Phone:_____________________  (speeds up orders should we have questions

Qty   Size     Prod#        Description of Item                Price Each   Total

                   Colorado Residents 4.60% Sales Tax: $______________
                                                               Subtotal: $______________
                                 Shipping Information Shipping: $_____________

                                                     Total Payment: $________________

Please make checks payable to: American Soccer Shirts Inc.

Credit Card Information

Full Name on Card (Please Print): ________________________________________

Credit Card Number: _________________________________________________ 

  Visa___    MasterCard___    Discover___    American Express___   Expiration Date:______ 

Cardmember Signature: _______________________________________________

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