TRIMONACK ORDER FORM

Print this form and mail to: TRIMONACK, 407 N. Railroad / Grand Ave., Roswell, New Mexico 88201

SHIP TO: _________________________________________________________

ADDRESS: ________________________________________________________

CITY: _________________________ STATE: _____ ZIP: ___________________

ATTENTION: ______________________________________________________

PHONE NUMBER IS NEEDED FOR SHIPPING: (_____) ___________________

TYPE OF PAYMENT: ___DISCOVER ___VISA ___MASTERCARD ___AMERICAN EXPRESS/OPTIMA

___CHECK OR MONEY ORDER

CHARGE CARD ACCOUNT NUMBER: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

CARD EXPIRES ON MO. ___ YR. ___

CARDHOLDER'S SIGNATURE _______________________________________

IMPORTANT: PLEASE CHECK ONE. IS THIS ORDER BEING SHIPPED TO:

__ 1) A BUSINESS __ 2) A BUSINESS AT A RESIDENCE __ 3) A FARM __ 4) A RESIDENCE

SPECIAL SAVINGS! FREE SHIPPING TRUCK SHIPMENT TO 48 CONTINENTAL UNITED STATES!! Be sure to compare our prices with other companies who do not include free shipping in their purchase price.

All orders shipped to Alaska, Hawaii, Puerto Rico, Guam, Virgin Islands, APO and FPO will be shipped freight collect by truck. You will pay the trucking company directly for the freight charges at the time of delivery.

E-Mail: TRIMONACK@Roswell-USA.com

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