Print this form out when you have entered the necessary information and send it to the address at the bottom of the form or fax it to us at 330-533-3459.

    FULL NAME: ____________________________________________________________

    TELEPHONE NUMBER: ___________________________________________________

    SHIPPING ADDRESS: _____________________________________________________

    EMAIL ADDRESS: ________________________________________________________

    YOUR ORDER: ___________________________________________________________

    MARK QUANTITY NEXT TO EACH ITEM:

                  .5” PAIR OF SHOE INSERTS - ($9.95)     _________
              1.00” PAIR OF SHOE INSERTS - ($10.95)   _________
              1.25” PAIR OF SHOE INSERTS - ($11.95)   _________
              1.50” PAIR OF SHOE INSERTS - ($13.95)   _________
              1.75” PAIR OF SHOE INSERTS - ($15.95)   _________
              2.00” PAIR OF SHOE INSERTS - ($16.95)   _________
              2.25” PAIR OF SHOE INSERTS - ($19.95)   _________
              2.50” PAIR OF SHOE INSERTS - ($23.95)   _________

If ordering (4) of each size deduct 18%, if ordering (8) of each size deduct 36% from
the individual pricing.

               SAMPLE PACK #1 1”, 1.5”, 2” PAIRS ----  ($29.95)  ________
               SAMPLE PACK #2 1”, 1.5”, 2”, 2.5” PRS -  ($47.95)  ________

   ULTIMATE SAMPLE PACK (ONE OF EACH SIZE) - ($86.52)  ________

                                          DUAL PACK .5”, 1.25” --  ($19.71)  ________
                                          DUAL PACK 1.00”, 1.50”- ($22.41)  ________
                                          DUAL PACK 1.25”, 1.75”- ($25.11)  ________
                                          DUAL PACK 1.50”, 2.00”- ($27.81)  ________
                                          DUAL PACK 1.75”, 2.25”- ($32.31)  ________
                                          DUAL PACK 2.25”, 2.50”- ($39.51)  ________

SHIPPING AND HANDLING:

  - REGULAR FIRST CLASS MAIL ----------------------  (ADD $6.95)   ________
  - PRIORITY MAIL --------------------------------------  (ADD $11.95)  ________
  - INTERNATIONAL SHIPPING (REST OF WORLD) - (ADD $12.95)  ________

AMOUNT OF US DOLLARS ENCLOSED  $________

CHECK OR MONEY ORDER TOTAL AMOUNT  $________

VISA/MASTERCARD/DISCOVER:

ACCOUNT NUMBER   ________________________________________________

THREE DIGIT CODE  ________

EXPIRATION DATE  ________

      NAME AND ADDRESS ON ACCOUNT IF DIFFERENT FROM ADDRESS ABOVE

      FULL NAME:   ______________________________________________________

      BILLING ADDRESS:    ________________________________________________

      SEND PAYMENT TO:

      Canfield Plastics

      10670 Lisbon Road

      Canfield, OH 44406

      or FAX To: 330-533-3459