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Please verify the information below one last time. The address must match your credit card billing address. If correct, simply complete the bottom portion of this form.
Billing Information:  
Primary Day Phone #:  
Secondary Phone #:  
Fax Phone#:  
Credit Card Information:
Visa Mastercard Discover American Express Check Enclosed (Payable to Audio Asylum)
Exact Name on Card:  
Number:     e.g., 5412-1234-5678-9012
Expiration Date:   / e.g. 01/15
CVV Code:  
  e.g., 860, 3 digit number on back of card or
  8609, 4 digit number on front of card (Amex)
(required, pick one)
  Undiagnosed $US 25.00
  Outpatient $US 50.00
  Inpatient $US 100.00 (Excellent choice!)
  Certifiable Loon $US 250.00
  Straight Jacket Club $US 500.00
  Frontal Lobotomy $US 1,000.00
  Fully Lobotomized $US 5,000.00
 If Other, please specify in $US