Please mail a copy of this form with your cheque,money order, or credit card number to: Goger Innovations Products, Inc., 1675 Cyrville Road, Unit 103, Ottawa, Ontario, Canada, K1B 3L7; or if you are ordering by fax, please fax a copy of this form to 613-741-8753. Fax or e-mail orders are accepted by credit card payment only, otherwise they will be processed upon receipt of your cheque or money order.

Please see the total amount for your order below this form. Write your cheque or money order to Goger Innovation Products Inc.

Note:For clearance see reason, Canada order paid by cheque will only be shipped 2 weeks after deposited and outside Canada ( International ) order paid by cheque will be shipped 4 weeks after deposited.

I. SHIPPING ADDRESS

Name: __________________________________________________________

Street address: ___________________________________________________

City: __________________________________________________________

State/Province:______________________________________________________

ZIP/P.C.: __________________________________________________________

Country:_______________________________________________________________

Phone:__(______)____________________________________________________
        (in case we have questions concerning your order)

Email: _________________________________________

Method of Payment: Card No._____________________
VISA (___) MASTERCARD (___) DISCOVER (___)
AMERICAN EXPRESS (___)
Expiry Date: ____________________
Cheque: (___) Money Order: (___)   C.O.D. (within Canada only): (___)

Quantity: (___)

Chin Muscles Tonifier Total Cost per Country of Residence

Canadian Residents

• Quantity: 1 Chin Muscles Tonifier
• Size: Standard Fully Ajustable
• Price: $124.95
• Shipping and Handling: $12.00 (via CANADA Post)
• subtotal: $136.95
• Taxes: GST (6%): $8.22
• PST (8%): $10.96 (Ontario Residents only)
• HST (14%): $19.17 (N.F., N.B., N.S. Residents)