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Personal Details
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Name:..........................................................................................................................................
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Address:......................................................................................................................................
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City:.................................................................Post Code:...........................................................
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Country........................................................................................................................................
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H/Phone:.........................................................W/Phone:.............................................................
Payment Details
Payment Type ( Please Circle )
Visa / MasterCard / AMEX / BankCard / COD(in AU) / Money Order / Cheque
| Credit Card No. |
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Name on Card:................................................Exp. Date:.........................
Signature:..........................................................Date:..............................
Product Order List
| Model # |
Description |
Color |
Price |
Quantity |
Sub Total |
| 10001_ab |
Butterfly |
Aqua Blue |
$12.95 |
? |
? |
| 10001_lp |
Butterfly |
Lavendar Pearl |
$12.95 |
? |
? |
| 10001_ps |
Butterfly |
Pink Shimmer |
$12.95 |
? |
? |
| 10001_vs |
Butterfly |
Violet Shimmer |
$12.95 |
? |
? |
| 10002_ab |
Phildo |
Aqua Blue |
$12.95 |
? |
? |
| 10002_lp |
Phildo |
Lavendar Pearl |
$12.95 |
? |
? |
| 10002_ps |
Phildo |
Pink Shimmer |
$12.95 |
? |
? |
| 10002_vs |
Phildo |
Violet Shimmer |
$12.95 |
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? |
| ? |
| ? |
| ? |
| Postage & Handling |
$6.95 |
| ? |
| Total |
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Print & E-Mail, Fax or Mail this form to:
SayStat Resources Inc.
P.O. Box 9200
Port Vila,
Vanuatu
Fax:
Email: [email protected]
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