O R D E R F O R M

Under-Tec Corporation

P.O. Box 11714, Pueblo, Colorado 81001

ITEM #1: MALE UNDER-EASE (with filter): $24.95 + $4.00 Shipping & Handling

ITEM #2: FEMALE UNDER-EASE (with filter): $24.95 + $4.00 Shipping & Handling

ITEM #3: EXTRA FILTER PADS (package of 2): $9.95 + $3.00 Shipping & Handling

ITEM #4: PLUS SIZE UNISEX (with filter): $29.95 + $4.00 Shipping & Handling

ITEM #5: GAS EATERS UNISEX (Perm. filter): $19.95 + $4.00 Shipping & Handling

(Shipping & Handling: $3.00 ea. additional Underwear/$2.00 ea. additional Filter Pkg.)

Item # XSm Small Medium Large XL XXL

Male: 1 *(24-27) (28-31) (32-35) (36-39) (40-43) (44-48)

Female: 2 *(20-23) (24-27) (28-31) (32-35) (36-39) (40-44)

Filter Pkg. 3 (One size fits all)

Plus Size 4 XXXX XXXX * (42-44) (45-47) (48-50) (51-53)

Gas Eaters 5 XXXX XXXX *(26-31) (32-37) (38-42) XXXX

Qty Item Size Price

# XSm Small Medium Large X-Lg XX-Lg

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*Waist Sizes in Inches

Tel: 888-433-5913 (Toll-Free Inside USA) Subtotal:

719-584-7782 (Outside USA)

S& H:

Website: www.Under-Tec.com (Outside USA $12.00)

Tax:

(3.9% in CO)

PRINT CLEARLY

TOTAL:

BILLING ADDRESS:

Name: ______________________________________

Address:

City ____________________________State ______________Zip

Telephone (area code lst)________________________email:

How did you learn about Under-Ease?

Rush Order? (extra $5.00) ____________ Current Date:

METHOD OF PAYMENT:

VISA _____ MASTERCARD _____ DISCOVER ______AMERICAN EXPRESS

CHECK ______ MONEY ORDER ______

Card # ____________________________________ Exp. Date (mm/yy)

SHIPPING ADDRESS: Check if Shipping Address is same as Billing Address______

Name:

Address: ________________________________________________________

City ____________________________ State ______________ Zip

Telephone (area code lst)

SPECIAL INSTRUCTIONS:

PLEASE HELP US: In order to better serve your needs and improve our products, we need customer information. Please complete the following (all information is confidential and will not be sold or go outside our office):

1. YOUR AGE GROUP: 19 or under____, 20-35____, 36-50____, 51-65____, 66 or over____.

2. Male____, Female____.

3. REASON FOR PURCHASE: Social____, Medical ____, Other ____,

4. State specific medical condition (optional)______________________.

5. First order____, Repeat order____.