                 DentureMan Registration Form


Name:    ____________________________________________________

Address: ____________________________________________________

City/Zip ____________________________________________________

Country: ____________________________________________________

Phone # : __________________________________________________


Send registration of Dentureman                    $10.00
BC residents add (7% sales tax)                    ______
Canadians  add   (7% GST)                          ______
Shipping and Handling                              $5.00
International orders add $2 extra S&H              _______


                                      Total     ____________

Pay by cheque, VISA, Mastercard or mail order to:

                       Nissen Ventures
                          PO Box 637
                      Surrey BC V3T 5L9
                            Canada


Card Number:____________________________  Exp Date _________
Signature  _____________________________



Payment by [] check   [] Money Order [] Mastercard [] Visa

============================================================]
Nissen Ventures                    Phone 604-436-5501
PO Box 637                         Fax   604-430-2210
Surrey BC V3T 5L9

           Make cheques payable to Nissen Ventures






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