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- Digital Physiognomy Order Form
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- Product nameá Digital Physiognomy
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- Product ID 7266-3
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- Unit Quantity:á ______
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- Price ($U.S.) _17.00_____
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- TOTAL AMOUNT ($U.S.)á _17.00_________
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- Payment Information:
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- First Name: ____________________________________________
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- Last Name: _____________________________________________
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- Company: _______________________________________________
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- Street Address: ________________________________________
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- ________________________________________________________
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- City: áá _______________________________________________
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- State/Province: ________________________________________
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- Zip/Postal Code: _______________________________________
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- Country: _______________________________________________
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- Daytime Phone: _________________________________________
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- Fax: ___________________________________________________
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- Email Address: _________________________________________
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- Payment:
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- ___ MasterCard ___ VISA ___ AMEX ___ Discover
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- ___ Check ___ Money order
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- For credit card orders:
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- Name on Card: __________________________________________
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- Credit Card Number: ____________________________________
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- Expiration Date:
- month ________________ year (4 digits) _________________
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- Signature : ____________________ Date: _________________
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