Prejac™ - Mail Order Form



Please print this form, enter the required information and mail to:

Austin Research Institute
Order Dept # PRE
P.O. Box 922
Hampstead, MD 21074
USA



ORDER SIZE OPTIONS

  The following are pricing options for Prejac™ (please circle one):

      Maryland residents please add 6% sales tax.  All prices are in U.S. Dollars.


PAYMENT OPTIONS

  We accept the following forms of payment (U.S. funds only):

  Please make your check or money order payable to: Austin Research Institute


CUSTOMER SHIPPING INFORMATION


  NAME: ________________________________________________________________________


  STREET ADDRESS: _______________________________________________________________


  CITY, STATE, ZIP: ________________________________________________________________


  COUNTRY/PROVINCE: _____________________________________________________________


  EMAIL ADDRESS: _________________________________________________________________

  Your email address is recommended so that we can provide you with tracking information.
  All of your information will remain completely confidential and will not be sold or given to anyone.



AGE VERIFICATION

  I hereby certify that I am at least 18 years of age.


  CUSTOMER SIGNATURE: ____________________________________________



MAIL THIS COMPLETED FORM (WITH PAYMENT) TO:

Austin Research Institute
Order Dept # PRE
P.O. Box 922
Hampstead, MD 21074
USA


Your order will be shipped within 48 hours of receipt of payment.

Copyright © 2001 - Present. Austin Research Institute. All Rights Reserved.