Please provide the following contact information:

First Name
Last Name
Home Phone
E-mail

Please provide the following ordering information. Use one line for each size of Funke' Flopz ordered

Children's sizes: 9/10, 11/12, 13, 1/2, 3
Adult sizes:  4/5, 6/7, 7-8-1/2, 9/10, 10/11

QTY	DESCRIPTION ( Example: Picture FF101 )	SIZE

	SHIPPING
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code

	Billing
Credit Card	VISA MasterCard Discover American Express
Card Number
Expiration Date
Name on Card
Comments & Questions