SSR Order Payment Page

This order payment page is for payment if you have already been fitted for a jacket.
Please use the pink copy of your order form to complete the first section below.

Questions? Call us at (800) 227-2040

Order Information

Student Name:

School Name:

Jacket Earned For:

IO Number: * This is the order form number on the top right of your pink copy.

Telephone Number:

Balance Due:

Billing Information

First Name:

Last Name:

Address:

City:

State:

ZIP Code:

E-mail:

Credit Card Information

I have:

Card Number:

Name on Card:

Expiration Date:

CVV: