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Patented Putting Order Form  -  06/01/10
Patented Putting
Dale Miller, Inc.
1820 Ridgemill Terrace
Dacula, GA 30019
www.PatentedPutting.com
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Call: 1-888-835-4563
In Atlanta: 678-482-8508
Fax: 678-298-9988
To Order Online: CLICK "Order Online" above DATE:_________________
 NAME: _________________________________________________________________________
 ADDRESS: _________________________________________________________________________
 CITY: _______________________________ STATE: _______ ZIP: _____________________
 EMAIL: _____________________________________ PHONE #: _________________________
 SEND BROCHURES?   ___YES      HOW MANY _______ P.O. #: _________________________
Golf Clubs: Item Description Price Shipping Subtotal
  _____SLW-01   Super Sand & Lob Wedge - Loft 70 Degrees $89.00 .00 $_____________
  _____LPP-BN   Hi Tech Hard Coat LoProfile Putter $99.00 .00 $_____________
Clubs Heads: Item Description Price Shipping Subtotal
  _____LPP-BN Head   Hi Tech Hard Coat LoProfile Putter - Head Only $49.00 $7.00 $_____________
Training Videos: Item Description Price Shipping Subtotal
  _____GLFVID-01   Patented Putting Training Video $15.95 $3.00 $_____________
Health Items: Item Description Price Shipping Subtotal
  _____        $_____________
* * * Shipping Outside US - Add $35.00 to each order    $_____________
GA Residents Only - Sales Tax @ 6.0%    $_____________
Send Check - Pay Invoice or use Credit Card - TOTAL    $_____________
Credit Card # _________________________________________________________________________
Card Type:   ______Visa  _____MasterCard   _____  AmEx_____   Discover    Exp. Date:___________
Name on Card:_________________________________________________________________