PENSION PROFILE, INC

P. O. Box 208, St. Petersburg, FL 33731

727- 821-4754, Fax 727-894-0250

pensions@pensionprofile.com

For online orders

CD-ROM ORDER FORM - PENSION PROFILE ^TM

Quantity: __________ @ $695 each $_____________

Shipping & Handling: $__________$15.00_________

Subtotal: $___________

Sales Tax: (if applicable for St of Florida, .07) $______________

Total: $_____________

PENSION PROFILE PENSION PROFILE PENSION PROFILE PENSION PROFILE PENSION PROFILE PENSION

Buyer’s Name: _______________________________________

Company Name: ______________________________________

Address: (for shipping) _____________________________________

City: ___________________________ ST: _____ Zip: ________

Phone: _________________________ Fax: _________________

Email: ________________________________________________

Referral Source:_________________________________________

Credit Card Number _____________________________________

Expiration Date ____________________ (Do not send this via email)

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FOR OFFICE USE ONLY

ORDER #________________

Amount: _____________________ Date Shipped:_______________