Two Old Goats Product Order Form

Order on line at www.twooldgoats.com or

Call Toll Free At 1-866-324-3787 Texas: 817-284-1208

Fax Completed Form to 1-480-237-5660

Mail To: Two Old Goats LLC.

3201 Mimosa Park Drive

Richland Hills, Texas 76118

Size Description Quantity Price Total

2 oz. Arthritis & Fibromyalgia Lotion ________ $5.95 _______

4 oz. Arthritis & Fibromyalgia Lotion ________ $9.95 _______

8 oz. Arthritis & Fibromyalgia Lotion ________ $17.95 _______

n/a Lotion Applicator, 17 1/2" Long ________ $14.95 _______

Shipping $4.95___

Subtotal ________

8.25 % Tax For Texas Residents Only _______

Total Due _______

Payment Information: ______Check _______Money Order _______Master Card _______Visa

______Discover _______Amex

Card Number: ____________________________________________ Exp. Date: ____________

3-Digit Code on back of card ___________

Billing Address of Card Holder

Name As It Appears On The Card _______________________________ Street______________________________

City _______________________ State __________________ Zip ________________

Daytime Phone _________________________

Ship To Address Name ____________________________Street_______________________________________

City _________________________ State _____________________________ Zip __________________