American Pharma Inc. Optipatch Order Form
Simply Print and Mail OR Fax
Toll Free Fax: 1-888-777-0038
Must be 18 years or older to purchase
Make Checks Payable to: Performance Marketing Ltd.
Please fill out the following form. Check the box next to the product
you wish to order, and then mark the quantity you wish to order.

Product
Quantity
Price
Amount
Optipatch Penis Enlargement 3+1Free
  
$159.97
 $
Optipatch Penis Enlargement 2
  
$109.97
 $
Optipatch Penis Enlargement 1
  
$ 59.97
 $
 

All prices are in US Funds.

Shipping charges: US = $10.00
Canada = $10.00
International = $19.95
 
Sub-Total
 $
+ Shipping
 $
+ Tax
 $
Total Order
$
   

Thank you for your Order.

Additional Information and/or
comments:

Credit Card Number (no spaces)

__________________________________________

Expiry Date________________________________

CVV2#____________________________________
(the number on the back of the card in the signature bar)

Card Type_________________________________

Make checks payable to:
Performance Marketing Ltd.
Send your order to:
PO Box 294
Cassidy BC
CANADA
VOR 1H0

Name:_____________________________________

Address:___________________________________

__________________________________________

__________________________________________

Phone:____________________________________

E-Mail:____________________________________

Ref. # (internal use only)