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Patented Putting Order Form  -  06/01/2018
Patented Putting
Dale Miller, Inc.
1820 Ridgemill Terrace
Dacula, GA 30019

www.PatentedPutting.com
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Call: 888-835-4563
In Atlanta:
678-482 8508
Fax: 678-298-9988
Ordering Online will be available soon DATE:_________________
 NAME: _________________________________________________________________________
 ADDRESS: _________________________________________________________________________
 CITY: _______________________________ STATE: _______ ZIP: _____________________
 EMAIL: _____________________________________ PHONE #: _________________________
 SEND BROCHURES?   ___YES      HOW MANY _______ P.O. #: _________________________
Golf Clubs: Item Description Price Shipping  
  _____SLW-01   Sand /Lob Wedge -Loft 68 $129.00 $7.00
  _____LPP-BN LoProfile Putter Head Only $169.00 FREE in U.S. $_____________
Putter Grips: Item Description Price Shipping $_____________
 __LPP- Grip LoProfile Putter Grip Only $21.00   Free on putter
* * * Shipping Outside US - Add $35.00 to each order    $_____________
GA Residents Only - Sales Tax @ 6.0%    $_____________
Send Check or use Credit Card - TOTAL    $_____________

Select Your Putter Grip: ____________________________________________________


Credit Card #
_________________________________________________________________________
Card Type:   ______Visa  _____MasterCard   _____  AmEx_____   Discover    Exp. Date:___________
Name on Card:_________________________________________________________________