Order Form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" rowspan="2" width=210 BGCOLOR="#99CC99" TEXT="#080000" bgproperties="fixed" background="03e8dfc3.jpg"> <bR> </td> <td valign="top" colspan=2 height=82 BGCOLOR="#CCCC99" TEXT="#080000" bgproperties="fixed" background="03f8dfe1esnpes.jpg"> <div> <FONT SIZE="5" COLOR="#000000" FACE="Arial" ><B>Physicians' Choice Acupuncture</B></FONT><B>     </B><B>|</B><B>     </B><A HREF="index.htm" TARGET="_top" TITLE="Physicians Choice Acupuncture"><U><B>home</B></U></A></div> <div> <A HREF="id2.htm" TARGET="_top" TITLE="Provider Profile"><U>Provider Profile</U></A>   |   <A HREF="id3.htm" TARGET="_top" TITLE="Bieg Health and Fitness Professional Per"><U>Bieg Health and Fitness Professional Personal Training   </U></A>   |   <A HREF="id4.htm" TARGET="_top" TITLE="Specialized Martial Arts Training"><U>Specialized Martial Arts Training</U></A>   |   <A HREF="id15.htm" 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<I>Order Form</I></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="521" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 75 WIDTH="517"><div> <I>CHINESE HERBAL WEIGHT LOSS TINCTURE</I></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="517"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="517" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <bR> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="573" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 39 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="39" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="557"><div> <B>Mail / Fax Order Form</B> </div> </tD> </tR> </TABLE></div> <bR> <DIV ALIGN="LEFT"></DIV> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="445" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 39 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="39" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="429"><div> Fax: 760-735-8291</div> </tD> </tR> </TABLE></div> <bR> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="127" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 25 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="25" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="111"><div> Ship to:<FONT SIZE="4" COLOR="#000000" FACE="Arial" > </FONT></div> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="633" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 23 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER><NOBR><div> ___________________________________________</div> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="633" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 23 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER><NOBR><div> ___________________________________________</div> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="633" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 23 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER><NOBR><div> ___________________________________________</div> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="633" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 23 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER><NOBR><div> ___________________________________________</div> </NOBR></tD> </tR> </TABLE></div> <bR> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="633" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER><NOBR><div> <B>Please indicate form of payment, allow 4-6 weeks for personal checks.</B></div> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="183" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="167"><div> CHECK _______</div> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="267" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER><NOBR><div> MONEY ORDER _______</div> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="523" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER><NOBR><div> CREDIT CARD _______ shipped in 24 hours</div> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="633" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER><NOBR><div> CREDIT CARD NUMBER ______________________________________</div> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="633" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER><NOBR><div> EXPIRATION DATE ___________________________________________</div> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="633" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER><NOBR><div> TYPE OF CARD _______________________________________________</div> </NOBR></tD> </tR> </TABLE></div> <bR> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="483" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 23 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="23" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER><NOBR><div> <B>DESCRIPTION</B> <B>QUANTITY UNIT COST</B> </div> </NOBR></tD> </tR> </TABLE></div> <bR> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="485" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 21 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="21" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER><NOBR><div> <FONT SIZE="1" COLOR="#000000" FACE="Felix Titling" >CHINESE HERBAL WEIGHT LOSS TINCTURE</FONT><FONT SIZE="1" COLOR="#000000" FACE="Tahoma" > </FONT>__________<I> </I></div> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="250" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 26 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="26" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER><NOBR><div> <B>$25.00</B><FONT SIZE="4" COLOR="#000000" FACE="Felix Titling" > </FONT><FONT SIZE="3" COLOR="#000000" FACE="Arial" >___________ </FONT></div> </NOBR></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="234"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="234" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <bR> <DIV ALIGN="LEFT"></DIV> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="261" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="9"><div>   </div> </tD> <tD VALIGN=CENTER><NOBR><div> <B>SUBTOTAL</B> __________</div> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="19" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="9" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="3"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="3" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="443" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="71"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="71" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="365"><div> Shipping & Handling Charges <FONT SIZE="3" COLOR="#000000" FACE="Felix Titling" ><B>$6.95</B></FONT></div> </tD> </tR> </TABLE></div> <bR> <bR> <div> <B>                                                                                                  TOTAL DUE: </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>_________ </B></FONT></div> <bR> <div> ___________________________________________<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Print name as it appears on Credit Card<FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <bR> <div> ___________________________________________<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Signature<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="188" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="178"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="178" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="3"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="3" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <bR> <bR> <div> <B>Mailing address:</B></div> <div> <B>Physicians' Choice Acupuncture</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B>1556 Corte Capriana</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <B>Escondido, CA 92026</B></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="188" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="178"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="178" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="3"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="3" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <bR> <bR> <bR> <bR> <bR> </td> </tr></table></body>