ORDER FORM
| Ancient Earth | Phone (435) 635-4452 |
| P.O. Box 441 | Fax (435) 635-5060 |
| Hurricane UT 84737 | Email kalder@netulink.com |
| Name | |
| Company | |
| Street Address | |
| PO Box | |
| City | |
| State/Province | |
| Zip/Postal Code | |
| Country | |
| Telephone (area code) | |
| FAX Number (area code) | |
| Shipping Preference | USPS Express USPS Priority |
| Name As It Appears on Card | |
| Card Type (Check one) | VISA MASTERCARD NOVUS/DISCOVER |
| Number | |
| Expiration Date | |
| Your Signature |
| ITEM | DESCRIPTION | PRICE |
| Merchandise Total | ||
| Shipping/Insurance | ||
| UT Residents Tax 6%(.06) | ||
| TOTAL |
| Print This Form and Fax to (435) 635-5060 |
| Thank You For Your Business |