--------------------------------------------------------------------------------

                          Talisman Order Form

--------------------------------------------------------------------------------



Product name      Talisman

Product ID        1333-4 

  
Unit Quantity:  ______

Price ($U.S.)   ______

TOTAL AMOUNT ($U.S.)  __________



Payment Information:


First Name: ____________________________________________

Last Name: _____________________________________________

Company: _______________________________________________

Street Address: ________________________________________

________________________________________________________

City:    _______________________________________________

State/Province: ________________________________________

Zip/Postal Code: _______________________________________

Country: _______________________________________________

Daytime Phone: _________________________________________ 

Fax: ___________________________________________________

Email Address: _________________________________________


Payment:


___ MasterCard ___ VISA ___ AMEX ___ Discover

___ Check ___ Money order


For credit card orders:


Name on Card: __________________________________________

Credit Card Number: ____________________________________

Expiration Date: 
month ________________ year (4 digits) _________________

 


Signature : ____________________ Date: _________________