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YOUR INFORMATION (Please fill in all pertinent boxes)
                   Mr.      Ms.      Mrs.      Dr. 
 
 

Full Name:
Co-inventor:
Company Name:
Street Address:
City:	State: Zip: Country:
Mailing Address:
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Date of Birth:	Occupation:
Home Phone:	Work Phone:
Fax Number:	Email:

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TOTAL PAYMENT
Please note: we offer a 5% discount for 5 or more orders of any item and a 10% discount for 10 or more orders of any item.  Please call toll free at 888-275-2757 for authorization for such a discount. Additionally, we are willing to do any of this work on an hourly basis with a retainer. Please see the retainer page for additional information.
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METHOD OF PAYMENT
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Credit Card Type: Visa  Mastercard  American Express  Discover
 
 

Expiration Date:
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