Clip&Talk ORDER FORM (Product Number 92964517988)


Name __________________________________________________________________

Shipping Address ______________________________________________________

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_______________________________________________________________________

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Phone Number ____________________________ E-mail ______________________


Clip&Talk 2.0                     Quantity __  x   $30.00(*) = ________

     CT, MA, MN, WA Residents Add Applicable Sales Tax      ___________

                                                    Total:_____________



Credit Card Information (for credit card order only):

Name (exactly as on card) _____________________________________________

Billing Address (if different from shipping address)

_______________________________________________________________________

_______________________________________________________________________

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Type of card: VISA _______  MC _______  Amex _______  Discover ________

Card Number ___________________________  Expiration date ______________

Signature _____________________________________________________________


(* $25.00 if order by sending check or money order to PC WholeWare)