****** ORDERED BY *******                     ****** SHIP TO *******   (If different)

NAME:          ________________________       NAME:          ________________________

Street:        ________________________       Street:        ________________________

City:          ________________________       City:          ________________________

State/Province:________________________       State/Province:________________________

Zip/PostalCode:   _____________________       Zip/PostalCode:   _____________________


Voice Phone:   ________________________       Voice Phone:   ________________________

Fax:           ________________________       Fax:           ________________________


Email Address: ________________________       Email Address: ________________________


** Merchandise Order **                                                              

PRODUCT NUMBER  PRODUCT NAME         COLOR/SIZE/STYLE   HOW MANY?  PRICE    TOTAL FOR 
                                                                            PRODUCT

______________  ___________________  _______________    _________  _______  _________

______________  ___________________  _______________    _________  _______  _________

______________  ___________________  _______________    _________  _______  _________

______________  ___________________  _______________    _________  _______  _________

______________  ___________________  _______________    _________  _______  _________

______________  ___________________  _______________    _________  _______  _________


      *** SHIPPING & HANDLING CHARGES ***                PRODUCT TOTAL:       _________


          IF YOUR PRODUCT TOTAL IS             |                                             

          LESS THAN $15.00 ........ ADD $5.00  |                                             
          $15.00 TO $24.99 ........ ADD $6.00  |                                             
      $25.00 TO $49.99 ........ ADD $7.00  |---------> SHIPPING & HANDLING: _________
      $50.00 TO $74.99 ........ ADD $8.00  |                                         
      $75.00 TO $99.99 ........ ADD $9.00  |                                         
      $100.00 OR MORE ........ ADD $10.00  |           TOTAL:               _________

Credit Card Information 
(Optional - complete only if paying by Credit Card)

Card Type: ________  Card Number: __________________  Card Expiry (eg. MM/YY):_________

Cardholder Name: ___________________   Card Holder Signature: __________________________

Please sign below if you are purchasing adult oriented merchandise:

 I am of legal age in my jurisdiction and consent to the purchase of sexual toys and products:

 Signature: ____________________________________       Date: ______________________