Order Form: Over the Counter Products

Order Form: PMS"14th DAY PILLS" FDA:ndc# 63656-999-01

THE 14TH DAY'S PILL
has been developed by our pharmaceutical team to help women who suffer from those commons symptoms of PMS such as swelling, bloating, pain, bad moods, headaches during the last week before the period.

Please fill out this form carefully.

Please provide the following information:

First name

Last name

Street address

Address (cont.)

City

State/Province

Zip/Postal code

Country

Work Phone

Home Phone

FAX

E-mail Please check it carefully

CAREFULLY ENTER THE FOLLOWING INFORMATION:

Product : 14TH DAY'S PILL

For how many months would you like?
Minimum 3 months:. $18.00 +shipping $9.00= $27.00

In order for us to get your products to you as soon as possible,
Please provide your credit card information:

BILLING

Credit card

Cardholder name

Card number

Expiration date

The cardholder agrees that" Diennet's PMS clinic" will automatically bill the subscriber credit
card.

Yes, I agree.

Yes No

Where did you hear about Pre Menstrual Syndrome?

Special Instructions, if any:

By check or money order to:
PMS Research Laboratory
9454 Wilshire Blvd. Ste #314
Beverly Hills, CA 90212
Tel: 800-272-3436
Fax: 310-277-7120
E-mail: pms@premenstrualsyndrome.com

*First name*
*Last name*
*Street address*
*Address (cont.)*
*City*
*State/Province*
*Zip/Postal code*
*Country*
*Work Phone*
*Home Phone*
*FAX*
*E-mail*	Please check it carefully

	BILLING
*Credit card*
*Cardholder name*
*Card number*
*Expiration date*