SIMPLY PRINT OUT THIS PAGE ON YOUR PRINTER, THEN COMPLETE & MAIL TO US AT THE ADDRESS LISTED BELOW.

                                                         ORDER FORM                                                            

         DESCRIPTION             QUANTITY      PRICE              SUBTOTAL                                 

Pkg of 5 Counterstrips - green   _______       $4.00 / pkg      ___________                                 

 Pkg of 5 Counterstrips - red    _______        $4.00 / pkg       ___________                                

                                                               SUBTOTAL            ___________                           

Sales Tax (Texas only) multiply order total by .0825             ___________                           

Shipping:  $1.00 for 1st pkg & .25 per pkg thereafter            ___________                           

                                                             ORDER TOTAL  $  ___________                           

   Please print the following:

NAME:  ____________________________________________________

ADDRESS: ________________________________________________

                   _________________________________________________

CITY:  ___________________________ STATE/PROVINCE: __________                

ZIP CODE: ____________   COUNTRY: _________________________

TELEPHONE: ____________________________  (not required: just in case we have a problem with the order)

WE ACCEPT CHECKS OR MONEY ORDERS.  PLEASE DO NOT SEND CASH.  PLEASE SEND PAYMENT TO: COUNTERSTRIP, P.O. BOX 761 BELLVILLE, TX 77418

PRIVACY POLICY:  Our privacy policy is simple: We will not reveal any information to anyone, ever...PERIOD.

Counterstrip is US Patent Pending and is protected by US & International Laws.

COUNTERSTRIP

P.O. BOX 761

BELLVILLE, TX 77418

Quantity discounts are available and for clinics, hospitals, wholesalers, retailers and distributors. Please e-mail your interests to: sales@counterstrip.com

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