Name:________________________________________________________

Address:______________________________________________________

City, State, Zip________________________________________________

Country:_____________________________________________________

Phone:___________________Fax:________________________________

Email:_______________________________________________________

Product(s):_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

Total Charge:________

Credit Card Type ____Visa _____M/C

Card Number:_______________________________ Exp:______________

2nd Card Number (if needed):_______________________________ Exp:______________

Signature:____________________________________________________


FAX this form to 1-608-788-9671

Or

Send check or money order to:

FAN Enterprises
907 S. 28th St
La Crosse, WI 54601