Mail Order Form
Complete and Mail to:
Jim Neil's TERSE Offer
3375 Areca Palm Avenue
Melbourne, FL 32901 USA

       Your Name:  ______________________________

    Phone Number:  ______________________________

 Times Available:  ______________________________

  E-Mail Address:  ______________________________



 Billing Address:  ______________________________

                   ______________________________

                   ______________________________

                   ______________________________

     Postal Code:  _______________

         Country:  ______________________________



Credit Card Type:  ______________________________

          Number:  ______________________________

Expiration MM/YY:  _______/_______


        Quantity:  _______


Shipping Address:  ______________________________

                   ______________________________

                   ______________________________

                   ______________________________

     Postal Code:  ______________________________

         Country:  ______________________________