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

I have enclosed my $14.00 payment in the form of a:

Personal Check ___ Money Order ___

Cashier's Check ___

Please send my Quick-Start Standard Kit to:

E-mail Address:

______________________________________

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: $________