• Please provide the following information:

  First Name
  Last Name
  Title
  Street Address
  Address (cont.)
  City
  State/Province
  Zip/Postal Code
  Country
  FAX
  E-mail
  Preferred E-mail Address	(jack)                                 @livingEZ.com
  First Choice	@livingEZ.com
  Second Choice	@livingEZ.com
  Third Choice	@livingEZ.com
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  Enter PayPal Confirmation #

• How do you wish to pay?:

        Check     PayPal

Submit this form ONLY if paying by PayPal!  Otherwise, print form, enclose payment, and mail to:

LivingEZ.com
P.O. Box 190
Jefferson, OR 97352

11/14/01