PO Box 641025
Miami, Florida 33164-1025
 

Date:________________________

Name:_________________________________________________________________________

Street Address:_________________________________________________________________

City:_______________________ State:_______________________ Zip:__________________

Home #:__________________ Work #:__________________E-Mail:______________________

Species of Bird____________________________________ Price of Bird:__________________

Amount Enclosed:_______________________________________________________________
                                (Minimum deposit is 30% of bird's price. Please note: Deposits on hatched babies are NON-REFUNDABLE.
                                 Once your deposit is received, a baby is reserved in your name and taken off our list of available birds.)

Method of Payment:

Check [ ]     Money Order [ ]     Visa [ ]     MasterCard [ ]

Card #:___________________________________Exp.Date:______________ CVV*_________
               (*Card validation code=the last three digits of the number printed in the Signature Panel on the back of the card)

Name on Card:__________________________________________________________________

Signature:_____________________________________________________________________

Airport City/Code:1st Choice_______________________2nd Choice______________________

DNA Sexing?_________________________ Health Certificate?___________________________
                          (Additional $35)                                                  (Additional $50)

Additional Comments:____________________________________________________________

______________________________________________________________________________