UNIVERSAL ARTS - ORDER FORM

MIRAGE II®- Stop Smoking Bank Order Form
(with Faux Handrolled Cigarette and English text)

Print, Fill out and Mail with Check or Money Order to UNIVERSAL ARTS, INC.
*U.S. FUNDS ONLY. to this Address:
UNIVERSAL ARTS, INC. - P.O. Box 367 - Bensalem, PA 19020 - U.S.A.

or DOWNLOAD PDF HERE and print it later when you are off-line.

Please provide complete and detailed shipping information:

Name:

Address:

City, State or Province:

Country:

Zip or Postal Code:

E-Mail:

*MIRAGE II® Stop Smoking Bank*	QUANTITY	UNIT PRICE	TOTAL
		$19.99
Add 6 Percent PA Sales Tax			\
USA Shipping @ $4.90 per Item
International shipping @ $9.00 per Item
		GRAND TOTAL
(Orders are shipped U.S. Mail within 2 to 5 Weeks Upon Receipt of Funds)