Last Name: First Name: Middle Initial:
Address: Apartment #:
City: State: Zip Code:
Please enter your credit card information:
Card Number:
Credit card expiration date:
On whose behalf are you making this purchase?
How many Office Buddies are you ordering?
Would you like a personalized plate for your Office Buddy?
If you answered yes, what would you like it to say?
Are you a first time customer?
If you answered no, where have you bought our products in the past? (check all that apply)
Who will be charged for the supply?
