Exerlopers Fitness Systems

ORDER FORM

MAILING INFORMATION

NAME:____________________________________

ADDRESS:_________________________________

__________________________________________

_____________________PC/ZIP:_______________

PHONE: (____)______-___________

FAX: (____)______-_____________

OTHER INFO:_______________________________

__________________________________________

METHOD OF PAYMENT

Please check one of the following.

MONEY ORDER___ CERTIFIED CHEQUE___

MASTER CARD___ VISA___ AMEX___

CARD NO._________________________________

EXPIRATION DATE____/____/____

SIGNATURE________________________________

Price per unit in US dollars.

ITEM

QUANTITY

PRICE PER UNIT

TOTAL

EXERLOPERS	________	199	$______.___
INSTA-PULSE 105	________	159	$______.___
INSTA-PULSE 107	________	149	$______.___
INSTA-PULSE WALL	________	389	$______.___
INSTA-PULSE FLOOR	________	399	$______.___
ANTENSE	________	169	$______.___
INSTA-RUNNER	________	399	$______.___
BODY-TRIM	________	59	$______.___

Thank you for your order. Have a nice day.

For more information please contact Biosig Instruments toll free at
1-800-463-5470 or Fax (514) 637-1353
Email: biosig@biosig.net
Mailing Address: PO Box 860, Champlain NY 12919
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