The Amazing Exercise Ball Order Form

Customer Information

Name:		* Please enter a valid name.
Email Address:		* Please enter a valid email address
Phone:	() -	* Please enter a valid phone number.

Billing Address:	Ship to billing address	Shipping Address:
Address Line 1:			* Please enter a Shipping Address. * Please enter a Billing Address.
Address Line 2:
City:			* Please enter a Shipping City. * Please enter a Billing City.
State:	Zip:	Zip:	* Please choose a Shipping State and/or enter a valid Zip Code. * Please choose a Billing State and/or enter a valid Zip Code.

Item	Color	Qty	Price	Ext. Cost	* You must order at least one (1) item.
Small Exercise Ball			@ 24.99/ea		* Please enter a valid quantity and/or select a color.
Medium Exercise Ball			@ 29.99/ea		* Please enter a valid quantity and/or select a color!
Large Exercise Ball			@ 34.99/ea		* Please enter a valid quantity and/or select a color.
Subtotal:
7.75% Sales Tax:
Shipping Method:					* Please select a shipping method.
Total: