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Date ________________________


Name _______________________

Company ____________________

Address _____________________




In reference to the order placed on __________________ (month & day) _____(year), we have received and fulfilled your request.  Payment on your order is now due and payable.  Please send your payment in the form of check, money order, VISA, or Master Card.  Please include your account/invoice number with your payment.  The total amount due is _______________ ($________).




Accounting Department


Account number:  ________________                              Invoice Number:  ________________


Amount Due:  ____________________                           Amount of payment:  _____________


Form of payment:  Check, Money Order, Visa, Master Card (circle one)

Credit Card Acct. No. ____________                                 Exp. Date: ____________________

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