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Order Form

Make Check Payable To:
DanaMedic
P.O. Box 12733
Raleigh, NC 27605

Name: _______________________________________
Address:______________________________________
Zip code:______________________________________
City:_________________________________________
Country:______________________________________
State:________________________________________

I order one JES Extender, which will arrive within 15 working days, with a 12 month international guarantee , and two week money refund. Money refund is excl. shipping.
The price is U.S. $ 990.00 incl. shipping and handling.

Every aspect of ordering and shipping will be handled with the utmost discretion.

Please select method of payment :

( _ ) Personal check (enclosed) or International Money Order ( _ ) (enclosed)

Credit card: ( _ ) Visa Card, ( _ ) Mastercard, ( _ ) Eurocard.
Card number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Exp. date: __ / __
Card account name: ________________________________
Signature (if Possible): _______________________________
Registration Name: _________________________________
E-mail: __________________________________________
Alternate contact: (Fax) ______________________________
Phone: __________________________________________
Address: _________________________________________

Thank you for purchasing The JES Extender