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 American Express Discover * Card #: _____________________ * Exp. Date: _____ * SELECT YOUR CD ORDER HERE USA ORDERS 1 Unit - USA - Total $16.50 2 Units - USA - Total $31.00 3 Units - USA - Total $45.50 INTERNATIONAL ORDERS 1 Unit - International - Total $21.00 2 Units - International - Total $40.50 3 Units - International - Total $58.00 - 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 $25.00 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