ORDER-FORM

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WE SHIP IN PLAIN PACKAGING
FOR PRIVACY AND DISCRETION

PLEASE PRINT CLEARLY

FULL NAME (AS IT APPEARS ON CREDIT CARD

FULL NAME _____________________________________

AMX CC# __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

DELIVERY ADDRESS _____________________________________

STREET

CITY STATE ZIP

___ XXTRA-CLEAN

___ READY-CLEAN

___ FAST-FLUSH

___ CONSTANT
CLEANSE

$54.95

$39.95

$34.95

$24.99

$51.95

$36.95

$31.95

$21.99

UNITS

TOTAL $

.

MONEY ORDER OR CERTIFIED CHECK ONLY PAYABLE TO COAST TO COAST IF NOT USING AMERICAN EXPRESS CARD

C&C/PASS THAT DRUG TEST
4074 COAL SPRING LANE STE.3A
GLEN ALLEN, VA 23060

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