ORDERED BY:  ____________________________________ Name  ____________________________________ Street Address  ____________________________________ City    ____________________________________ Province                             Postal Code       ____________________________________ Telephone ____________________________________ Email Address

SHIP TO: same as ordered by? Yes___ No___ ____________________________________ Name ____________________________________ Street Address  ____________________________________ City    ____________________________________ Province                             Postal Code

Code Description (Include; Size, Colour) Quantity Price Each Total

Payment: Enclosed, please find my:

Order Total

Cheque or money order payable to Lunatic Adventures Inc.(no post dated cheques please)

Post. & Hand.

Visa

Expiry Date (mm/yy)

Sub Total

Card #

Postage & Handling Rates Over   $35.00                 $12.00 Under $35.00                 $ 6.00 Outside of Canada Add Extra                     $ 7.00

7% GST

8% PST

Signature_______________________________

Total

Mail To: Lunatic Adventures Inc., 250 The East Mall Suite #1691, Toronto, Ontario M9B 6L3 or Phone: (416)518-0209