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Order Form

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Order Form

Business Name: ________________________________________


Billing Address: ________________________________________
Name of Authorized Person: ______________________________
Email Address: _________________________________________
Business Phone Number: _________________________________

Credit Card or Paypal Account


Visa/MasterCard/Discover Card #: _______________________________
Expiration: _____________ Security #: _________

Billing Zip Code: _________

Television Choice #1 or #2 or #3: __________


Phone Number for Reservations: ____________________
Website URL: ___________________________________
I hereby authorize to have my Paypal or Credit Card above to be charged ____ $750 one
time on this date _____________OR _____$600 on this date _____________, and $600
to be charged 30 days from this date and finally $600 to be charged 60 days from this date
for the Infomercial package.
_______________________________
Name of F&B Rep

_________________________________
Name
_________________________________
Signature Approving Order
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