Pinhole Glasses Order Form

Name +AF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBf-

Delivery Address +AF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXw-

+AF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXw- Zip +AF8AXwBfAF8AXwBfAF8AXwBf-

Phone +AF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8- Fax +AF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8-

Email +AF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8-

I would like to place an order for the following+ADs-
(Models are displayed at http://www.pinholes.com/pinholeprices.htm)

+AF8AXwBfAF8-  Pairs of Steno Pinhole Glasses +AEA- +ACQ-US25.95 +AD0- +ACQAXwBfAF8AXwBfAF8AXw-
+AF8AXwBfAF8-  Pairs of Mode Pinhole Glasses +AEA- +ACQ-US32.95 +AD0- +ACQAXwBfAF8AXwBfAF8AXw-
+AF8AXwBfAF8-  Pairs of Classic Pinhole Glasses +AEA- +ACQ-US32.95 +AD0- +ACQAXwBfAF8AXwBfAF8AXw-
+AF8AXwBfAF8-  Pairs of Premier Pinhole Glasses +AEA- +ACQ-US39.95 +AD0- +ACQAXwBfAF8AXwBfAF8AXw-

      Postage and Handling +AEA- +ACQ-US8.95/pair +AD0- +ACQ- +AF8AXwBfAF8AXwBfAF8AXwBf-
      (Free delivery for 2 or more pairs)

                                     Total: +ACQ- +AF8AXwBfAF8AXwBfAF8AXwBf-

Payment details

+AF8AXwBf- Cheque enclosed (please ensure payment is made in +ACQ-US. If your local 
currency is not +ACQ-US, you can request an international bank draft from your local 
bank. Please note that we do not accept payment by money order).
  
+AF8AXwBf- I am paying by credit card. My details are as follows+ADs-

Card type:  +AF8AXw- Visa  +AF8AXw- Mastercard  +AF8AXw- AMEX  

Card number +AF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXw- Exp. Date +AF8AXwBfAF8-/+AF8AXwBfAF8AXw-

Name on card +AF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8AXwBfAF8-

Please fax the above order to Natures Energies in Australia on 
3-9752-0234 (Number includes Australian country call code 61). You may
alternatively send the order to+ADs-

Natures Energies Health Products, 
+ACI-Timber Ridge+ACI-, 13 Ridge Road, Kallista,+AKA-
Victoria, 3791, AUSTRALIA

Deliveries to Australia will take 2-3 days. Deliveries to international
addresses take 1-3 weeks.