DELIVERANCE FOR YOURSELF AND OTHERS U.S. ORDER FORM

Canada and the U.S. Only!

Print this form and mail with a money order to:
(make money orders payable to Odette Ouellette)

Odette Ouellette
P.O. Box 24
Russell, Ontario, Canada
K4R 1C7

(Please Print Clearly)

DATE ___________________________


NAME ___________________________________________________________


STREET ADDRESS ______________________________________________________________


CITY ____________________________________  PROVINCE/STATE  ____________________


POSTAL/ZIP CODE _______________________   COUNTRY ____________________________


TELEPHONE _______________________________  


EMAIL (please print clearly)  ___________________________________________