Please
print and complete this form and mail or FAX to: 1-620-227-8474
| Item | Quantity |
X
Price |
Total
Price |
| BOSS 2000-3 | ______ | $460.00 |
________ |
| MVP 700 | ______ | $460.00 | ________ |
| "EASY LOAD" Ring Loading System Does not include tube or loading cone |
______ | $49.95 | ________ |
| Ultimate
II Rings Please circle size: X I II III IV (X is smallest and IV is largest) Minimum order of Two (2) Rings Required. |
______ | $15.00 |
________ |
| Ultimate
Rings Please circle size: #0 #1 #2 #3 (#0 is smallest and #3 is largest) Minimum order of Two (2) Rings Required. |
______ | $20.00 | ________ |
| Adapter
Bushings Please circle size: A B C (A is largest and C is smallest) |
______ | $20.00 | ________ |
| Regular 2"
x 8" Penile Tube Please circle type: Twist On Slip On |
______ | $25.00 | ________ |
| Large 2 1/4" x
10" Penile Tube + Loading Cone + Bushing Please circle type: Twist On Slip On |
______ | $75.00 | ________ |
| Loading Cone | ______ | $15.00 | ________ |
| BOSS 2000-2 Replacement Pumphead | ______ | $120.00 |
________ |
| Rejoyn Replacement Pumphead | ______ | $75.00 | ________ |
| Water Soluble Jelly Lubricant | ______ | $4.50 | ________ |
| Zipper Carrying Case | ______ | $20.00 | ________ |
| BOSS System Instructional Videos | ______ | $10.00 | ________ |
| BOSS System User's Manual | ______ | $6.00 | ________ |
| Subtotal: | ________ | ||
| US Shipping
& Handling: $15 Standard Shipping (UPS) $8 Standard Shipping (US Mail) $25 Express Shipping (2-3 days) $45 Rush Shipping (overnight) |
________ | ||
| International
Shipping
& Handling: $28 Canada $25 Mexico $65 South America $80 Europe $72 Africa $62 India $50 Asia |
________ | ||
| Sales Tax for Kansas Residents: 7.3% | ________ | ||
| Total: | ________ | ||
| Minimum Order of $30 | |||
| Full
Name |
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| Address |
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| City |
State |
Zip |
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| Country |
Phone |
Email
Address |
| Signature |
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| Credit Card Number | Expiration Date | |
1701 N 14th Ave
Dodge City, KS 67801