THREE WAYS TO ORDER:

                                                      Print-Out Form

 1                                                                                          2                                                                            3

 REGIMINT                                                           PRICE                                           TOTAL

                                                                                 S & H  (USA&Canada Only):             $6.00

                                                                                 S & H International: $13.00    $

                                                                                 6% Sales tax Florida:                $

                                                                                 Total Amount Enclosed           $

PAYMENT METHOD:

Make your check to:                                                                                         

                              Regimint                                                  Card No.__________________

                              P.O.Box 590974                                       Exp. Date___________

                              Fort Lauderdale, Fl. 33359

SHIPPING ADDRESS:

 

NAME

STREET ADDRESS                                                                         APT.

CITY

STATE                                                                                             ZIP

PHONE                                                                                           EMAIL