PRESCRIPTION ELECTRONICS, INC., Order Form

Name:____________________________________________

Address:____________________________________________

____________________________________________________

Phone: _______________________

Email : _______________________

ITEM ORDERED	PRICE	HOW MANY	TOTAL
`EXPERIENCE`	`$300`	`______`	`_____________`
`YARDBOX`	`$200`	`______`	`_____________`
`RxOVERDRIVER`	`$200`	`______`	`_____________`
`CLEAN OCTAVE BLEND`	`$200`	`______`	`_____________`
`THROB`	`$250`	`______`	`_____________`
`OUTBOX`	`$300`	`______`	`_____________`
`DEPTH CHARGE`	`$250`	`_____`	`_____________`
`VIBE-UNIT`	`$400`	`______`	`_____________`
`FACELIFT`	`$250`	`______`	`_____________`
`DUAL-TONE`	`$300`	`______`	`_____________`
`GERM___________________________`	`$250`	`______`	`_____________`


	SUBTOTAL:		`_____________`
Shipping:			`_____________`
TOTAL:			`_____________`

PAYING BY CHECK OR MONEY ORDER:

Mail to:

PRESCRIPTION ELECTRONICS, INC.
PO BOX 42233
PORTLAND, OR 97242
U.S.A.