----------------------------------------------------------------- INNERTALK - When Believing In Yourself Matters! E-Z FAX-IN OR MAIL IN ORDER FORM ----------------------------------------------------------------- To place your order by fax or mail, simply fill out this handy Order Form and fax it to us anytime day or night at (509) 244-6461. You may phone your order in by calling 509-244-6362. Or mail completed form, along with your check or money order for the correct total, to: Progressive Awareness Research, P.O. Box 1139, Medical Lake, WA 99022 We usually ship within 48 hours ----------------------------------------------------------------- Bill To: ----------------------------------------------------------------- Name ______________________________________________________ Address ______________________________________________________ City __________________________________ State _____________ Country _____________________ Postal/Zip Code ________________ Phone _____________________ E-Mail _________________________ ----------------------------------------------------------------- Ship To: (if different than Bill To: above) ----------------------------------------------------------------- Name ______________________________________________________ Address ______________________________________________________ City __________________________________ State _____________ Country _____________________ Postal/Zip Code ________________ Phone _____________________ E-Mail _________________________ ----------------------------------------------------------------- PAYMENT INFORMATION: ----------------------------------------------------------------- _____ Personal / Company Check _____ Money Order (Checks will be held until they have cleared the bank). _____ MasterCard _____ Visa _____ American Express _____ Discover Card # _______________________________ Exp. Date ______ / ______ Signature ____________________________ ----------------------------------------------------------------- ORDER INFORMATION ----------------------------------------------------------------- Item # Sound-Track Qty Title Each Total ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- REMEMBER: BUY 4 GET THE 5TH ITEM FREE (of equal or lesser value) ----------------------------------------------------------------- SUB-TOTAL $ --------------------- TAX $ --------------------- SHIPPING $ --------------------- GRAND TOTAL $ ----------------------------------------------------------------- Guarantee and Return Policy ----------------------------------------------------------------- Materials All of our CDs, Tapes and Videos are guaranteed against defects in material for one year. ----------------------------------------------------------------- Replacement If a tape simply breaks or wears out, return it to us and we will replace it for just $5.00 and postage. ----------------------------------------------------------------- Satisfaction All of our InnerTalk products are guaranteed to assist you in changing the way in which you speak to yourself. To benefit fully, use the products at least one hour per day for 30 days. If you are a first time customer, we recommend that you follow closely the usage guidance on your product. If you feel our products do not work for you, please call Customer Services prior to returning the product to receive return documentation. We reserve the right to refuse refund should our return policy procedure not be followed. ----------------------------------------------------------------- Consumer Advice Notice All our self-help products are sold as educational properties only. We do not claim or imply any medical benefits. Nothing in our product range is a substitute for proper health care. Consult your doctor if you have questions regarding healthcare. Pricing and postage charges are subject to change. We retain the right to refuse to do business with anyone for any reason at any time. ----------------------------------------------------------------- Note to Health-Care Professionals We offer certain programs at no cost with a note from the attending health-care professional. For example, our Cancer Remission program will be issued free of charge as long as we are ensured that the patient remains under professional care and is not using the product as a substitute for professional care. ----------------------------------------------------------------- Our Commitment We are in the business of helping people help themselves. We believe you deserve the best in mind training technology and we do our best to bring it to you. ----------------------------------------------------------------- SHIPPING CHARGES * ----------------------------------------------------------------- Product Subtotal Shipping Charge Up to $19.99 $5.00 $20.00 to $62.99 $6.50 $63.00 to $99.99 $8.50 $100.00 to $199.00 $12.00 $200.00 to $299.99 $15.00 $300.00 and up $20.00 ----------------------------------------------------------------- Canada: add $7.00 to shipping charge. ----------------------------------------------------------------- Foreign: For all international orders please contact us for shipping rates. Customs, duty and taxes may apply. ----------------------------------------------------------------- Delivery Time: Orders are normally shipped within 48 hours. Expect 5-7 day delivery for domestic orders. ----------------------------------------------------------------- In A Rush? 2-Day delivery add $12 to Shipping Charge. ----------------------------------------------------------------- * Shipping charges subject to change based on rate changes. Form #09b09a06s