Please provide the following contact information:

First Name
Last Name
Title
Organization
Work Phone
Home Phone
FAX
E-mail

Please provide the following ordering information:

NeckEase			QTY
	small	$40
	large	$45
Eye Pillow		$25
Sinus Pillow		$25
Mitt/Muff (circle one)	small	$40
	large	$45
Packs	Basic	$30
	Large	$40
	X large	$45
Wraps	Elbow	$40
	Neck	$40
	Knee	$45
	Back Small	$50
	Back Large	$55
FootEase	Small	$55
	Large	$60
Keyboard Support		$15
Mouse Support		$10
Star		$30
Cecil		$30
Spot &  Fisheze		$30
Heart		$15
CD Flute Medicine		$15

	BILLING
Credit Card	VISA MasterCard American Express Diner's Club Discover
Cardholder Name
Card Number	_______________________________
Expiration Date	V-Code:_______

	SHIPPING
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Phone #	_______________________________