Dennis R Zamzow

Billing and Shipping Information

Billing Address
	Name:
	Address:
	Address continued:
	City:
	State/Province:
	Postal Code:
	Country:
	Daytime Phone:
	Evening Phone:
	E-mail Address:
	Yes, I'd like to receive special offers.
	No, I'd prefer not to be contacted with any special offers.

Shipping Information
	Shipping:
	Ship-To address same as Bill-To address

Shipping Address (if different from above)
	Name:
	Address:
	Address continued:
	City:
	State/Province:
	Postal Code:
	Country:
	Daytime Phone:
	Evening Phone:
	Special Instructions:	<merc_dynamic name=special noshow=false action=SC_GET_FIELD return=Result TableName=ShipTo RowName={shipToRow} FieldName=Special>