Fill out all the fields you feel are applicable to your inquiry. Fields marked with " ! " are required.

Please provide the following contact information.

 ! First Name 
! Last Name 

! Please provide at least one phone number. We may use this information 
to validate an order, confirm order information, or if there is a problem. Or we 
may call or email you just to say thanks!

Work Phone 
Home Phone 
E-mail 

If you would like to provide any special instructions regarding 
the contact information you provided, such as special 
times to call you, please feel free to do so:

Please provide the following ordering information:

This is your order:

QUANTITY	DESCRIPTION	PRICE EA.
1 2 3 4 5	HI-RES R/C VIDEO SYSTEM - HIGH POWER (100 mW)	$1179.00

QUANTITY	DESCRIPTION	PRICE EA.
0 1  2 3 4 5	EXTRA BATTERY PACK  (700 mA SANYO NICAD WITH CONNECTOR)	$49.95
0 1  2 3 4 5	I Scape (HEAD MOUNTED DISPLAY WITH 1400 mA BATTERY AND CHARGER)	$699.95

 

Please provide the following billing information:

! method: Please selectCredit cardPersonal checkOther if other:

If you prefer not to provide the following credit card information via the Internet, 
we will be happy to contact you instead. Please indicate your preference below

 Yes, please contact me ... AS SOON AS POSSIBLE !!!No need to contact me. Here's my credit card information.Please select

Credit Card  Please selectVISAMasterCardDiscover
Cardholder Name 
Card Number 
Expiration Date 

                 SHIPPING

This is the address where you want your order to be shipped to:

! Address 
Address (cont.) 
! City 
! State/Province 
! Zip/Postal Code 
! Country 

If necessary, please provide any special shipping instruction below: