ProSizer - Mail Order Form

ProSizer™ - Mail Order Form

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

Austin Research Institute
Order Dept # PRO
P.O. Box 522
Hampstead, MD 21074
USA

ORDER SIZE OPTIONS

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

Only $ 136.95 for the ProSizer™ Extender (Extender device only)

Only $ 360.95 for the entire ProSizer™ System (Extender + everything else)

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):

cash (U.S. Dollars)

money orders

cashier's checks

personal checks

  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 # PRO
P.O. Box 522
Hampstead, MD 21074
USA

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