Par-Stats Payment Information
Order #: 04I13Q521
Order Date: 09/13/2004
Item: Premium
Amount Due: $29.00

Boswell Piddle
Select Payment Type
Check/Money Order

Print This Form and Mail with Payment to Address below
Please Make Check or Money Order Payable to:

Par-Stats, Inc.
P.O. Box 770110
Lakewood, OH 44107

When Finished, Press "Submit Payment" Button Below
To Complete Your Order and Receive a Receipt by E-Mail