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          ORDER FORM / PURCHASE ORDER

          DATE:                          P. O. NUMBER: 
 
          CO. NAME:                    PHONE: 

                         ORDERED BY:             POSITION:
 
                                         EMAIL:              FAX: 
 
          BILL TO:              SHIP TO: 
 
          VENDOR:      29SCENTS, INC.                       PHONE:    303-518-6115
                              P.O. BOX 23                             EMAIL:      info@29scents.com
                              FRANKTOWN, CO 80116           FAX:         303-805-8443
     ****************************************************************************************************************************************
          QUANTITY                                 DESCRIPTION                                    PRICE
         (Check One)                            (Check One)     (Custom Design*)      
            200              1 Color  2 Sides                       
            500              2 Color  2 Sides                                       
           1000             3 Color  2 Sides                          
           2500             Shipping                                                            
                                    Tax (CO Residents add 5.1%)                             
                                    TOTAL                                                              
     ********************************************************************************************
                                              Letter:                           ---- A B C D E F G H I J K L M N O P Q R S T U V W X Y Z      Custom Design: 
                                                             Color for Area "A":         
                                                             Color for Area "B":         
                                                             Color for Area "C":         
                                              Scent:                           Blueberry Bouquet Bubble Gum Cherry Candy Pop Cinnamon Citrus Coconut Flower Fresh Forest Fruits Fresh Green Apple Lavender Lemon Lilac Mint Orange Peach Pina Colada Pine Pineapple Raspberry Rose Spice Spring Garden Strawberry Vanilla White Floral Wildflower
                                              String Color:                  White Orange Black Green Red Yellow Blue Pink
                                                        Wording on freshener:   
         Click for Examples           Header Card Inscription  

    PAYMENT: (Check One)         Invoice (see P.O. # above)     Check Enclosed       Credit Card:       
      Name on Card: Card Number: 
      Credit Card        -------------- Mastercard Visa    Expiration Date:      CSC#:  (last 3 digits on back of card)
      Address:  City:    State:   Zip:   
      Phone:         email: 
                                                        
    AUTHORIZED SIGNATURE: ___________________________________________
            (required for Purchase Orders)
        *Custom Design: Please send design and information via email or Fax

          Please sign and fax to (303) 805-8443 or mail to address above.

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