order


	We accept purchase orders:


	by Mail, by Phone, by Fax, by E-mail if you fill in the form below.


	*We will let you know if there is a Dealer in your area.*


	Lancet Pharmaceutical Co. #523-250 Eglinton Ave. E. Toronto Ontario CANADA M4P 3E1 Tel: (416) 778-6653 Fax: (416) 778-0655


	Burma Latex Inc. #523-250 Eglinton Ave. E. Toronto Ontario CANADA M4P 3E1 Tel: (416) 778-6653 Fax: (416) 778-0655


	Title


	First & last name


	Company (if any)


	Address


	Telephone


	Fax (if any)


	E-mail


	Wrinkle Therapy^TM $40 for one jar; add $20 for another jar


	Please check all that applies!


	Quantity


	Miracle Foot Repair USA$20 for one jar; USA$30 for two jars


	Quantity


	Mold Craft 8 oz (250 ml) $6.85 each


	Quantity


	Mold Craft 16 oz (500 ml) $8.85 each


	Quantity


	Mold Craft 33.8 oz (1 L) $17.oo each


	Quantity


	Mold Craft 128 oz (3.78 L = 1 gallon) $46.oo each


	Quantity


	Burma Liquid Mask $6.00 one jar;


	Quantity


	Burma Plaster 2.2 lb ( 1 kg) $3.00 each


	Quantity


	Burma Plaster 5 lb. ( 2.27 kg) $6.00 each


	Quantity


	Burma Plaster 7 lb. ( 3.2 kg) $7.95 each


	Quantity


	Shipping


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