PBN Creations

PO Box 621404               Littleton, CO 80162

(303) 798-2216 Phone      (530) 323-9174 Fax

FAX, PHONE OR MAIL ORDER FORM

ORDER PowerBall Net products with your VISA, MASTERCARD, AMERICAN EXPRESS or DISCOVER Cards. Complete this form, sign it, and FAX it to (530) 323-9174 or MAIL this form to the above address with a check or money order made payable to PBN Creations. For additional information or PHONE ORDERS call (303) 798-2216. No Risk 45 day money back guarantee (minus Shipping/Handling).

METHOD OF PAYMENT

[   ] Check      [   ] Money Order     [   ] Credit Card 

PERSONAL INFORMATION

Ordered by:__________________________________________________________

Address: ____________________________________________________________

City: ____________________________  State: _____________   Zip: ___________

Day Phone: ___________________     Evening Phone:________________________

Fax:____________________        Email Address: ____________________________

CREDIT CARD INFORMATION

[   ] VISA      [   ] MASTER CARD      [   ] AMERICAN EXPRESS        [   ] DISCOVER

Card Number:____________________________     Expiration Date: ____________

Card Holder's Signature:______________________________

Ground Shipping Charges (US Domestic)             Call for charges other than ground