Pinhole Glasses Order Form

Name ________________________________________________

Delivery Address ________________________________________________________

___________________________________________________________ Zip _________

Phone ____________________________ Fax __________________________________

Email ____________________________

I would like to place an order for the following;
(Models are displayed at http://www.pinholes.com/pinholeprices.htm)

____  Pairs of Steno Pinhole Glasses @ $US19.95 = $_______
____  Pairs of Mode Pinhole Glasses @ $US32.95 = $_______
____  Pairs of Classic Pinhole Glasses @ $US32.95 = $_______
____  Pairs of Premier Pinhole Glasses @ $US32.95 = $_______

      Postage and Handling @ $US8.95/pair = $ _________
      (Free delivery for orders consisting of 2 or more pairs)

                                     Total: $ _________

Payment details

___ Cheque enclosed (please ensure payment is made in $US. If your local currency is not $US, you can request an international bank draft from your local bank. Please note that we do not accept payment by money order).
  
___ I am paying by credit card. My details are as follows;

Card type:  __ Visa  __ Mastercard  __ AMEX  

Card number ___________________________________ Exp. Date ____/_____

Name on card __________________________________

Please fax the above order to Natures Energies in Australia on 
+61-3-9752-0234 (Number includes Australian country call code 61). You may
alternatively send the order to;

Natures Energies Health Products,
13 Ridge Road, 
Kallista, Victoria, 3791 
Australia

Deliveries to Australia will take 2-3 days. Deliveries to international
addresses take 1-3 weeks.