Triple Your Endurance
Rapid Response Order Form

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FAX this form to 1-419-754-2253

___ Enclosed is my check, money order or credit card order for $_____________.00 plus $7 S&H ($17 foreign orders)

Totaling $__________________.00

Charge my (Note - You can use more than one card to complete this order):

Visa, Mastercard, American Express

Card Number:_____________________________________________ Exp. Date:______________

Signature: __________________________________________

Print Name: _______________________________________________________________________

Address 1: _________________________________________________________________________

Address 2: _________________________________________________________________________

City: ______________________________________ State: __________________________________

Zip Code: ______________________________ Country: __________________________________

Date of Birth: _____________________________________

Telephone: _______________________________________________

Fax Number: _____________________________________________

E-Mail: __________________________________________________

Or Mail This Form To:

Vince Palko Enterprises, LLC
7051 Ramblehurst Dr.
Sylvania, OH 43560