DHSB Order Form

<% If Request.querystring("print") = "true" then %>

Mailing Address:
    DHSB
    P.O. Box 30938
    Honolulu, HI 96820
Fax Number: 
    808.833.0935 <% End If %>

*Please fill in the method of payment section
and sign form before mailing or faxing.

<% If Session("State") = "HI" then %> <% End If %> <% If Session("gifts") > 0 then %> <% For i=1 to Session("gifts") %> <% Next End If %>

Name:	<%=Session("Name")%>
Address:	<%=Session("Address")%>
	<%=Session("Address2")%>
Phone:	<%=Session("Phone")%>
Number of Orders:	<%=Session("Orders")%>
Shipping and Handling: ($8 per package)	$<%=FormatNumber(Session("Shipping"), 2)%>
Subtotal:	$<%=FormatNumber(Session("Subtotal"), 2)%>
Tax (4.166%) :	$<%=FormatNumber(Session("Tax"), 2)%>
Total:	$<%=FormatNumber(Session("Total"),2)%>
Gift Orders:
Receiver Name #<%=i%>:	<%=Session("Rec" & i & "Name")%>
Address:	<%=Session("Rec" & i & "Address1")%>
	<%=Session("Rec" & i & "Address2")%>
Phone:	<%=Session("Rec" & i & "Phone")%>

Please circle a method of payment:

   Visa                 Mastercard

Card Name:	__________________________________
Card Number:	---
Expiration Date:	/
Authorizing Signature:	__________________________________

<% if request.querystring("print") <> "true" then %> <% End If %>