Mail-In/Fax Order Form_Levitator Shoe Lift Insoles the world's leader in height increasing products. Prices start at $3.99

Mail-In/Fax Order Form

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 - ($8.95)     _________
              1.00” PAIR OF SHOE INSERTS - ($9.95)     _________
              1.25” PAIR OF SHOE INSERTS - ($10.95)   _________
              1.50” PAIR OF SHOE INSERTS - ($12.95)   _________
              1.75” PAIR OF SHOE INSERTS - ($14.95)   _________
              2.00” PAIR OF SHOE INSERTS - ($15.95)   _________
              2.25” PAIR OF SHOE INSERTS - ($17.95)   _________
              2.50” PAIR OF SHOE INSERTS - ($19.95) _________

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 -------------------- ($27.95) _______

SAMPLE PACK #2 1”, 1.5”, 2”, 2.5” PAIRS ------------- ($44.50) ________

ULTIMATE SAMPLE PACK (ONE OF EACH SIZE) - ($84.50) ________

                                        DUAL PACK .5”, 1.25” -- ($17.90) ________
                                      DUAL PACK 1.00”, 1.50”- ($20.65) ________
                                          DUAL PACK 1.25”, 1.75”- ($23.50) ________
                                      DUAL PACK 1.50”, 2.00”- ($26.00) ________
                                  DUAL PACK 1.75”, 2.25”- ($29.75) ________
                          DUAL PACK 2.25”, 2.50”- ($29.95) ________

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

FAX TO: 330-533-3459