LIFEDATA® CARD & Insert cards @$9.95 each:

Quantity Ordered (check one box) Total

One, $9.95

Two, $19.90

Three, $29.85

Four, $39.80

Five, $49.75

Total number         

Total $                 

California residents add: 8.5% sales tax $                 

Shipping and Handling $2.50

Grand Total $                 

Please mail this form with a check for the above grand total.

To use a credit card, fill out below:

Type of card:  Mastercard Visa Discover

Card Number                                               

Exp date              
3 digit number on reverse of card              

Please allow 10 days for arrival although in most cases,
the cards will arrive sooner.