Silver Pine Industries Order Form
For NEWAYS Products

Referring Distributor ID# 7100-30-005

Customer Name:
Address:      City:
State:           Country:
Zip/Postal:       Phone:
E-Mail Address:

If Ship To Address is Different Than Above Address
Please Enter Complete Address in "Special Instructions" Below
Code Quantity Description Cost Total
Credit Card Payment Method:

M/C Visa AMEX Discover
Card Number: Card Expiry: Name On Card: 		Subtotal:
Shipping:
Sales Tax:
Total:
Special Instructions or Comments

NOTE: This form is NOT WORKING at the present time
Please print the form once you've filled it out and fax it to (604)275-9502.
This is a temporary problem with our web host and we hope to have it resolved soon.
We are very SORRY for any inconvenience this has caused!!



PLEASE NOTE: The above information is for processing of orders only and will be held strictly confidential. We do NOT sell or give your e-mail address or any other personal information to anyone.