Yes I want to purchase a STiKA!
Important !! Print out this form, fill it in and fax it to 450-449-0144. This will insure that information is not transmitted over the net.
Name : _____________________________________________________
Address : __________________________________________________
__________________________________________________
__________________________________________________
Phone:_____________________ Fax: _____________________
Email: ______________________________________________________
Please send me my STiKA C.O.D. and add $10.00 C.O.D. charges.
Signature:
Please charge my VISA the amount of $314.00 for one STiKA.
Card Number :________________________________________________
Expiry date :_________________
The card is in my name ( please print ) :______________________________
Signature:
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