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Process an Online Payment for a Custom Amount
Use this secure custom order form to process payments for anything other than the open stock items in the Shop or memberships (e.g. limited edition items advertised in the Heisey News, raffle tickets, monetary donations). Your browser must support secure sockets layer.

Name:
Shipping Address: No PO boxes please.
Country:
Telephone Number:
Fax Number:
E-mail Address:
Are You an HCA Member?:	Yes No
Amount of Purchase: Be sure to include 7% Ohio sales tax and shipping costs if applicable.
Description of Purchase: For raffle tickets, please indicate item for which you are purchasing tickets.
Card Type:	Visa MasterCard
Card Number:
Expiration Date on Card: Ex: 10/2003