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Dept.12,NorthWales,PA19455 CHARGE ORDERS: VISA MASTERCARD ...

Ifyouwouldlikethisentireordersenttoan addressotherthanyourown,pleasefillinbelow. Ifyouwishpartofitshippedtoadifferentaddress,pleasecheck( ) thoseitems,fillinbelow,andadd$4.99foreachadditionaladdress.