EDWARD M. LICHTEN, M.D., P.C.
189 TOWNSEND STREET -- SECOND FLOOR
BIRMINGHAM, MICHIGAN 48009
Office Telephone: 248.593.9999   FAX: 248.593.9037
 
PRINT CLEARLY in DATA ENTRY FIELDS
 
[     ]            INTERESTED IN:(1) EXEC PHYSICAL
                                                    (2) LABORATORY TESTING
                                                    (3) VITAMINS, FACE CREAMS, SLEEP ITEM
                                                    (4) CONSPIRACY BOOKS
 
[_________________________] FIRST NAME
[_________________________] LAST NAME  [___] MIDDLE INITIAL
[_________________________] ADDRESS 1
[_________________________] ADDRESS 2
[_________________________] CITY
[______________][__________] STATE ZIP-CODE
[_________________________] TELEPHONE NUMBER
[_________________________] E-MAIL ADDRESS

VISA  MC   DISCOVER AM. Express            (Circle)  Type of Credit Card
[_________________________] CREDIT CARD NUMBER
[______________][__________] EXPIRATION DATE   V-code PRODUCTS                                                  

PRINT QUANTITY in DATA ENTRY FIELDS

ITEM#  QUANTITY     Description    
#0001[      ]@ $ 11.99 DIABETES   CONSPIRACY 
#0002[      ]@ $ 11.99 ESTROGEN CONSPIRACY        
#0003[      ]@ $ 11.99 INSOMNIA  CONSPIRACY
#0004[      ]@ $ 11.99 VITAMIN     CONSPIRACY    not available
 #0005[      ]@ $ 49.99 CD-ROM LECTURE SERIES  (10 Video& Audio Lectures)
 #0006[      ]@ $ 99.99  Sleep Aid     
#0007[      ]@ $  99.99 Vitamins: Female     Discounted!
 #0008[      ]@ $  99.99 Vitamins: Male         Discounted today!
#0009[      ]@ $ 99.99  Cosmetic:    Moisturizer, under eye serum & facial scrub
#0010[      ] @$ 29.99   Paperback Edition of 3 Books
#0025[      ] @ $1,099.   CASE of 12 BOTTLES of VITAMINS
  
[       ]  Amount Enclosed: ________________   Time and date: __________

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Shipping and Handling: $  9 (one book, cosmetic, vitamin or CD)
Shipping and Handling: $19 (multiple books, vitamins)