PotentialPlus.org Mail Order Products Order Form

Smart Mail Order Formula

Potential Plus Publishing (ABN 18 068 992 450)

Order Form

We use http://www.eMatters.com.au
for secure order processing

Fill in the rest of the form & press the SUBMIT button.

NOTE: All prices are in Australian Dollars. Statement will show own currency conversion.

PLEASE SUPPLY CORRECT DETAILS WHERE REQUIRED FOR ACCURATE SHIPPING

PRODUCT #1

Full / Contact Name *

E-mail Address *

Company Name

Street Address* *

Suburb

City / State

Zip / Post Code

Country

Phone Number *

Fax Number

How Did You Hear About Us *
Credit Card Information

Credit Card Type *

Card Holder
*

Card Number *

Expiration Date *

3 digit CVV number on the back of VISA/MC card *

Indicates Signing

NOTE: CREDIT's are issued on the purchase price & ONLY if the goods were damaged in transit.
Original Shipping Costs are (NON REFUNDABLE)

* Please Supply correct address for shipping

©2002 Potential Plus Publishing
PO Box 1038 Mountain Gate 3156 VIC AUSTRALIA

Email: CLICK HERE

PRODUCT #1
Full / Contact Name	*
E-mail Address	*
Company Name
Street Address*	*
Suburb
City / State
Zip / Post Code
Country
Phone Number	*
Fax Number
How Did You Hear About Us	*
	Credit Card Information
Credit Card Type	*
Card Holder	*
Card Number	*
Expiration Date	*
3 digit CVV number on the back of VISA/MC card	*
Indicates Signing