FLESH CAFFEINE ORDERFORM (print this form for mail or fax) Ordering Information Please provide the following information - print clearly. * These fields are required. * Name: _______________________________________ * Address: _______________________________________ * City: _______________________________________ * State: _______________ *Zip:_______________ * Country: _______________________________________ * Phone: _______________________________________ Fax: _______________________________________ Email: _______________________________________ * Card Type: Visa MasterCard AMEX Discover * Card #: _____________________ * Exp. Date: _____ * SELECT YOUR CD ORDER HERE ORDER PRICING 1 Unit - Continental US Shipping add $5.20 - Total $18.70 2 Units - Continental US Shipping add $5.20 - Total $32.20 1 Unit - Alaska, Hawaii, Puerto Rico add $7.80 - Total $21.30 2 Units - Alaska, Hawaii, Puerto Rico add $7.80 - Total $34.80 1 Unit - Canadian Shipping add $9.20 - Total $22.70 2 Units - Canadian Shipping add $9.20 - Total $36.20 1 Unit - International Shipping add $10.80 - Total $24.30 2 Units - International Shipping add $10.80 - Total $37.80 - all prices include shipping and handling - * Sales Tax: NJ Residents must add 6% * Order Total: _________________ * Signature: _______________________________________ Fax your order to 609-466-8160 or Mail with check or money order payable to; UEC PO Box 126 Ringoes, NJ 08551 Your order will be shipped promptly. THANK YOU! NOTE: THERE WILL BE A $50.00 CHARGE FOR ANY RETURNED CHECKS - DO NOT SEND A BAD CHECK! UEC - PO Box 126 - Ringoes, NJ. 08551 - Tel: 609-466-8101 Fax: 609-466-8160