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1- Print this form.
2- You are ordering the revolutionary Power Enlarge Patch.
The number one sexual enhancement patch in the world.
3- Fill in all of the fields with your information. Please
specify which package you are ordering! Click
Here to view options
4- We accept cashier's check, money order, or credit
card.
5- Mail this form and payment to:
(Make checks or money orders payable to Cybermed Industries)
Cybermed Industries Inc.
1201-1020 View St
Victoria, BC Canada
v8v4y4
6- Please note that all prices are in US dollars!
| Billing
/ Shipping Information |
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| *Required
Field |
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| * Full
Name: |
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| * Address:
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| * City:
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_____________________ |
| * State: |
_____________________ |
| * Zip/Postal
Code: |
_____________________ |
| * Country:
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| * Phone
Number: |
_____________________ |
| * E-mail
Address: |
_____________________ |
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Please circle the credit card you are using.
Visa – Master Card
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| Name On Credit Card: |
_____________________ |
| Credit Card Number: |
_____________________ |
| Expiration Date: |
_____________________ |
| CVV2 Code: |
_____________________ |
| Quantity: |
_____________________ |
| Total Price: |
_____________________ |
| Signature: |
_____________________ |
| * E-mail Address: |
_____________________ |
Click
Here For
shipping/privacy/security
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Order
by Phone: 1-866-442-4447
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| Our
discreet team of customer service representatives are
ready to take your order now. Call anytime 1-866-442-4447.
Visa and Mastercard accepted. For additional ordering
options, click on the links below .... |
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