First Name______________________________ Last Name_______________________________

Shipping Address _________________________________________________________________

Additional Address__________________________________________________________________

City _________________________________________________ State________________________

Postal Code ________________________________________Country ________________________

Telephone ________________________________ Fax ___________________________________

Check Type of card: Visa______ MasterCard _____ American Express ____ 

Card Number_______________________________________________________________

Exp Date ______/______ 3 or 4 Digit Code _____ email address ______________________________

Credit Card Billing Address ______________________________________________________

City _________________________________________ State ______________________________

Postal Code _______________________________ Country __________________________________

Additional address information ____________________________________________________________

Print name on credit card ___________________________________________________________

By signing this form I authorize HelmetsRus of Port Orange, FL USA
to charge my credit card for goods purchased from them. Approximate purchase amount $____________