BODYSAFE – SAFETY SOLUTIONS

ORDER FORM

1066 Dunolly Road, Phone/Fax: 03 5469 7202

Dunolly, Victoria, 3472 Mobile: 0419 320 201

www.bodysafe@iinet.net.au www.bodysafe.com.au

Print out this form, fill in your details and send with a cheque, money order or your credit card details to the above address:

Name: ……………………………………………………………….

Street: ……………………………………………………………….

Town: ……………………………………………………………….

State: …………………………….. Postcode: ……………………...

PAYMENT METHOD:

□ Cheque Full name on card: ………………………………….

□ Money Order Credit card Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

□ Credit Card Type of card (eg. Visa): ………………. Expiry Date: …./…..

ORDER DETAILS: Please tick item/s required, below.

Tow Bar Protector. Speed Awareness Indicator. Sleep Assistant for Snoring

or Sleep Apnoea.

□ BarGuard □ Speed Saver □ Snooze-Well

Costs: $15.00ea $25.00ea $25.00ea

Quantity: ……………………………………………………………………….

Postage: $ 5.00 $3.00 $ 3.00

Any Amount Any Amount Any Amount

Total Amount: …………………………………………………………………..

(Phone A/H 03 54697235 for trade and fleet prices)