MUSLIMAMATCH.COM PRINTABLE ORDER FORM
	
	Please print the following form and return it by mail with the correct payment
	by bank check or money order (if you are paying via Western Union or Moneygram please post this form separately) 
	to: MuslimaMatch.com, Box 201, 2666 Danforth Avenue, Toronto, Ontario, M4C 1L7, Canada. Make checks and money orders
	payable to MuslimaMatch.com.
						
	First Name:___________________________________________________________

	
	Last/Family Name:___________________________________________________________

	
	E-mail Address: (valid address only - please print neatly- all lower case)________________________________________________________

	
	E-mail address again:_________________________________________________________________
	
	Postal Address:________________________________________________________Town/City:_________________________State/Prov:_______________________
	
	Postal Code:______________________Country:_________________________
	
	Telephone number:(optional)____________________________________ Fax number:(optional)______________________________________
						
	I am... ___ Searching for myself ___ Helping a family member ___ Helping a friend
						
	How did you hear about MuslimaMatch.com? 
						
	___ Search engine ___ Word of mouth ___ E-mail ___ Flyer/poster ___ Newspaper ___ Direct Mail
						
	AGREEMENT TO TERMS
	
	I am at least 18 years old and have read and agree to MuslimaMatch.com's terms of use and privacy policy. 
						
	I understand and agree that MuslimaMatch.com is an informational service only and makes no other promises. 
	I hereby waive any and all claims against MuslimaMatch.com, its employees and directors. 
						
	Signature required:__________________________________________________________Date:_________________
																						    (mm/dd/yyyy)
	ORDER INDIVIDUAL CONTACT INFORMATION   
	
	* A "contact" may include the woman's postal address, e-mail, telephone number or any other method in which she would 
	like to be contacted.
						
	How should we send you the contact information?
						
	___ via E-mail (NO EXTRA CHARGE) ___ by Standard mail (add $5.00 to your total) ___ via Fax (add $10.00 to your total) 
	___ by Registered Postal Mail (add $12.00 to your total) ___ via FEDEX or UPS (add $25.00 to your total)						  
						
	All prices are in US Dollars
	
	1 "contact" = $10         2 "contacts" = $18           3 "contacts" = $27
						                              
	4 "contacts" = $32       5-9 "contacts" = $35-45      10-15 "contacts" = $60-80
	
	16+ "contactes" = $91.20+ (each "contact" at this level is $5.70) 
	
	To order "contacts" please write neatly the profile numbers of the women whose "contacts" you want to receive. 
	Sorry, No Split Orders - you cannot pay for some of your order now and then pay for some of it later. 
		
	1._________2._________3._________4._________5._________6._________7._________
	
	8._________9._________10.________11.________12.________13.________14.________
	
	15.________16.________17.________18.________19.________20.________21.________
	
	22.________23.________24.________25.________26.________27.________28.________
	
	29.________30.________31.________32.________33.________34.________35.________
	
	36.________37.________38.________39.________40.________41.________42.________
						
	In case any or your selections above are not available at the time your order is processed, and in case some selections 
	are typed twice. Please choose alternate "contacts" so that we can process your order without delay.
	
	Alternate 1 ________ Alternate 2 ________ Alternate 3_________ Alternate 4_________
		
	If you want to order more than 42 "contacts", please attach a second sheet of paper.
		
	TOTAL # OF "CONTACTS" REQUIRED =______ TOTAL "CONTACT" COST $________
	
	METHOD OF DELIVERY COST (e-mail delivery costs nothing extra)$________
						
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	TOTAL AMOUNT ENCLOSED (OR ENROUTE) $________
						
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	PAYMENT METHOD 
						
	___ Bank Check/Draft (US dollars drawn on US or Canadian Bank)(Make check payable to MuslimaMatch.com. Order held until check clears) 
	
	___ International Postal Money Order or Money Order drawn on a US or Canadian bank (in US dollars). Make it payable to MuslimaMatch.com.  
	
	___ Western Union (Send to E. Aymer - We will wait for your payment to be processed before fulfilling your order)
	
	___ Moneygram (Send to P. Aymer - We will wait for your payment to be processed before fulfilling your order)
		   
	All payments should be in US dollars. Bank checks/drafts should be issued by U.S. or Canadian Banks and made payable to MuslimaMatch.
	
	Some US/Canadian banks with international offices: Citibank, American Express, HSBC, Chase Manhattan/JP Morgan, Royal Bank of Canada,
	Bank of New York, Bank of Nova Scotia, Bank of America, ScotiaBank, CIBC