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