Application Form: (Please Print Clearly)

1. (Select Country) ____________________________

2. Name to accept mail in: _____________________

3. Code word or Number for future instructions

______________________________________

4. Name to forward mail to you: (Please note. One personal name & one Company name is acceptable in most cases. See each country as we may be able to arrange mail in unlimited names). _________________________________________________________________

5. Address: _________________________________

6. City & Postal Code: ________________________

7. Country: _________________________________

8. Special Instructions: ___________________________________________

___________________________________________

9. Payment Method:

Tick below for your preferred method of remittance: Once we receive your completed order form we'll email you the Western Union, Liberty Reserve or Bank Wire remittance details. Thank you.

[ ] Western Union [ ] Bank Wire [ Liberty Reserve or [ ] MoneyGram

[ ] Credit Card -

Type of Credit Card [ ] Visa [ ] MasterCard [ ] American Express [ ] Diner Club

Name as it appears on credit card :

___________________________________________

Billing address: _____________________________

___________________________________________

Credit Card Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

CCV 3 or 4 digit number on credit card _ _ _ _

Expiration date _ _ / _ _ _ _

Charge my credit card (don't forget postage deposit plus 5% for CC surcharge)

US$ ______________________________________

Signature: __________________________________

Please INCLUDE your e-mail address or fax number in case we need to contact you regarding this order. Thank you

______________________________________________________