SEND THIS ORDER FORM AND PAYMENT TO:
KEEP SMILIN
Rt. 1, Box 201B
Meeker, OK 74855          
     

 PHONE: (405)279-1116
  FAX: 405-279-1116
  EMAIL: smile@keepsmilin.com
YOUR NAME___________________________________ PHONE#___________________________
ADDRESS______________________________________ ZIP CODE:_________________________
CITY/STATE____________________________________ COUNTRY_________________________

Please give us your telephone number or email address in case of problems.
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SHIPPING & HANDLING (USA/Canada)
(FOREIGN)

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SUB-TOTAL
$5.00
$15.00
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Payment Type:
___Check or Money Order - MAKE PAYABLE TO: KEEP SMILIN
___Credit Card orders must fill out and sign the following:Card Type:____Mastercard____Visa
Name on Card:___________________________________________
Expiration:____________Card#:_____________________________
Amount:$_____________Signature:__________________________
Your Email Address(optional):_______________________


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