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Patented Putting Order Form  -  06/01/10
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
To Order Online: Updating online Store DATE:_________________
 NAME: _________________________________________________________________________
 ADDRESS: _________________________________________________________________________
 CITY: _______________________________ STATE: _______ ZIP: _____________________
 EMAIL: _____________________________________ PHONE #: _________________________
 SEND BROCHURES?   ___YES      HOW MANY _______ P.O. #: _________________________
Golf Clubs: Item Description Price Shipping Subtotal
  _____SLW-01   Sand & Lob Wedge - Loft 68 $109.00 $7.00
  _____LPP-BN   Hi Tech LoProfile Putter $149.00 FREE in U.S. $_____________
Clubs Heads: Item Description Price Shipping  
 __LPP- Head   LoProfile Putter - Head Only $99.00   $7.00  
* * * Shipping Outside US - Add $35.00 to each order    $_____________
GA Residents Only - Sales Tax @ 6.0%    $_____________
Send Check - Pay Invoice or use Credit Card - TOTAL    $_____________
Credit Card # _________________________________________________________________________
Card Type:   ______Visa  _____MasterCard   _____  AmEx_____   Discover    Exp. Date:___________
Name on Card:_________________________________________________________________