Todd Salat Shots Order Form

When placing an order, please include the following information:

Quantity	Product Name	Size		Price (with shipping)
			$
			$
			$
			$
			$
			$
Total:			$

The Shipping charges will be combined whenever possible and you will be reimbursed.

Name on Card	*
Credit Card #	*
3 Digit Code on back	*

Billing Address	*
	*
Billing City	*
Billing State	*
Billing Zip	*
Day Phone	*
Evening Phone	*
E-Mail	*

Card type*
Exp*
Shipping Same as Billing
Shipping Name
Shipping Address

Shipping City
Shipping State
Shipping Zip

* Required

Comments or "To "
for book personalization:

Sign up for the Salat Shots Mailing List
(Private, confidential, and never for sale)

Yes
No

ThanxSalat for your order
Call (907) 250-4711
to place a phone order.

or Print and Fax to:
(907) 333-3367

or Print and Mail to:

Todd Salat
645 G Street, Suite 100 #798
Anchorage, AK 99501