Dr. Kaplan Order Form

To mail your order, please print this form to your computer and mail it to us.
Or fax your order (credit card orders only) to: (919) 266-6366

NAME:________________________________________
ADDRESS:_____________________________________
CITY______________ST:______ZIP:_______________ 
COUNTRY:_________________
PHONE #:__________________________ (required)
E-MAIL:____________________________

Ship to address, if different:
ADDRESS:_____________________________________
CITY______________ST:______ZIP:_______________ 
COUNTRY:_________________
PHONE #:__________________________ (required)
E-MAIL:____________________________

METHOD OF PAYMENT (Check one):

_____ Check or Money Order Enclosed  (Make payable to "Dr. Kaplan")
Payment by check in US dollars drawn on an American bank or by international money order.

_____ Credit Card

_____ VISA
_____ MasterCard
_____ AmEx		 Credit Card #:_____________________________________
Name As It Appears On Card:_________________________________
Expiration Date:________________
Signature (required for credit cards):______________________________

Dr. Kaplan's Items

Option #1 -- Deluxe Pump w/ Guage and One Penis Cylinder

  Expansion Cylinder fits over penis
(This cylinder will fit 90% of the population.)
(Professional enlargement instructions and daily record sheet included.)

Quantity: __________ @ $158.00 ea. + S/H (see below)

Option #2 -- Electric Pump w/ Assembly and one Penis Cylinder

  MEGAVAC Electric Vaccum Pump (completely assembled and ready to use)
Expansion Cylinder: fits over penis
(This cylinder will fit 90% of the population.)

Quantity: __________ @ $286.00 ea. + S/H (see below)

Option #3 -- Electric Pump w/ Assembly, Deluxe Pump w/Gauge and one Penis Cylinder

  MEGAVAC Electric Vaccum Pump (completely assembled and ready to use)
Single hand held trigger pump.
Expansion Cylinder: fits over penis
(This cylinder will fit 90% of the population.)

Quantity: __________ @ $375.00 + S/H (see below)

SUBTOTAL AMOUNT: $_______________
CALIFORNIA RESIDENTS ONLY  --  Add 7.5% sales tax:  $_______________

SHIPPING AND HANDLING CHARGES:  $_________________
U.S./Canada: $12.00
Foreign Outside U.S./Canada: $25.00 for Hand Held Pump, $65.00 for Electric Pump

GRAND TOTAL:  $_________________
U.S. Funds Only

MAKE CHECKS AND MONEY ORDERS TO "DR. KAPLAN"

You may mail this form to:

Dr. Joel Kaplan
Dept. Net
P.O. Box 12733
Raleigh, NC 27605