Instructions : Print this form and mail to address below or fax to
949-348-1915. Send questions to [email protected].
                 
Newart
PO Box 2412
Mission Viejo, CA 92690-2412       PLEASE  PRINT  CLEARLY

Name _________________________________________

Address ______________________________________

City _________________________ State/Providence_____________ Postal Code ____________

Country ___________________  Email address : _________________________

   Yes - please add me to your private mailing list : _____        NO! Do not add me:______
Please enclose check or money order payable to Newart. PLEASE PRINT CLEARLY.
My signature certifies that I am over 21 years of age and will not hold NewArt
 liable for the use or misuse of any of the devices purchased. I understand no
 guarantees have been made or implied and that purchases are not returnable.

Sign __________________________________________   Date : _____________________

Cylinders :   Select this for more info on selecting the proper size cylinder.Lucite Expansion Cylinders,
standard sizes of 1 3/4" to 3" inside diameter and 9" to 12" length - $65.00 each. If you're
not sure what size to order send your dimensions, erect length along top & girth and we will send
the appropriate size Order sizes carefully as cylinders and pumps are not returnable for health reasons. 
You need both a pump and a cylinder if you are beginning.

Cylinder         Inside Diameter       Length     Quantity      Price      Total

#1                     _____ (i.e, 2")    ____     ______   X    $65.00    $______

#2                     _____ (i.e., 2")   ____     ______   X    $65.00    $______

Other Item ____________________________________________________________    $______

Brass Hand Pump :    Quantity ______    X  $35.00                          $______
Nipple tubes in pairs : 
Small - 1/ 2" ____  Quantity (# of pairs)     X $55.00                     $______
Medium  3 /4" ____  Quantity (# of pairs)     X $55.00                     $______

Scott Taylor instructional  video - VHS Tape _____ Quantity X $15.00       $______

If ordering Package A (Cylinder, Pump, Video) enter $108.00      Subtotal  $______

California residents add 7.75% tax                               CA Tax    $______
Video alone add $4.00 for shipping.
Other orders up to $130.00 add $10.50                          SHIPPING    $______
Foreign countries add $15.00 for shipping.                         
                                                                    Total  $______
Credit Card Orders :
Credit CARD NUMBER:______________________________________ EXPIRES _______

NAME as it appears on Credit Card:___________________________________________

Visa ____  Mastercard ____   American Express:____ Discover:___