HSIN TEN ENTERPRISE (HTE) USA, INC. ---ORDER FORM - PLEASE PRINT

17 Dupont Street, Suite 2, Plainview, NY 11803, USA

Customer Service: 631-454-1600; Order Department: 800-547-1510; Fax 800-547-1508


For Office Use Only:	Assigned ID No.:  A___________	Other:_____________

Sponsor's Information:  Name: Vernon E Spicer   ID No.: A126139

APPLICANT'S INFORMATION: -------------------------- Today's Date: ________

Mr./Ms.  First Name: _________________  MI: ___  Last Name: __________________


Social Security No. (SSN) or Employer Identification No. (EIN): ______________  


Street Address: ______________________________________________________________


City: ________________ County__________ State: _____ Zip Code: ________Country: ___________


Daytime Telephone No.:____________

Payment Method (Please circle one): ----- Check / Visa / MasterCard / AmEx / Discover

Credit Card Information:  Card No.: ___________________  Exp. Date: __________


Card Holder's Name: _______________________  Signature: ____________________________  


For Office Use Only: __________

Description				                	Unit Price   Amount

The Chi Machine SM-330 (Sun Harmony Aerobic Exerciser) (New item #SS001C2)
(no cost if returned within 2 Weeks; 2 year warranty)-includes handling charge-$490.00-----$	
Sales Kit including Registration Fee to become a Distributor) (New item #ABA001002)--$24.95-----$
Hothouse-(New item #SY010A2)-------------------------------------------$899.00----$
Freight (applies to shipments outside of the continental USA) -----------------------------$
Local Sales Tax (excluding Hawaii and Alaska) ---------------------------------------$
Total ------------------------------------------------------------------------$

Note:

Please sign below then fax or mail this form to Hsin Ten Enterprise USA, Inc.

Authorized Signature:_________________________

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