YOUR INFORMATION 

	Name:    

	Address: 

	City:    

	State:   

	Zip:     

	Email:   

	Phone:   

	Fax:     

	How Did You Learn About Us:   
	
	
	By signing in the Purchaser box below -- I state that I have read and understand the 
	purchase guarantee, legal disclosure and disclaimer, performance disclosure and 
	tax responsibility information provided.

	Purchase Guarantee:    
	
	
	I request the Bank Resale Program and the Series 4000 - 90% + Buy Sell Program 
	immediately. I understand I am waiving my refund period and will not be entitled to a 
	refund of any kind by accepting programs. My name is entered in the Signature box - 
	being the same as my signature.

	Waiver:    
	
	
	COMMENTS: