Quick-Start Standard Kit Order Form


United Refund Services
1236 Rio De Janeiro Ave. Suite E
Punta Gorda, FL 33983


I have enclosed my $16.00 payment in the form of a:

Personal Check ___ Money Order ___

Cashier's Check ___


Please send my Quick-Start Standard Kit to:

Name: ____________________________________

Address: ______________________________ Apt.# _____

City: ____________________________________

State: ___________________ Zip Code: __________

Please include the following state listing with my kit:

___________________________


I would like additional state listings with my kit.

Please include the following states:
(State abbreviation) ____/____/____/____/

(Add $4.00 per additional state listing)

Total: $________


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