FITNESS SYSTEMS MFG. CORP.

_____CERTIFIED CHECK
_____OTHER

PAYMENT BY (CHECK ONE):   

_____MONEY ORDER
_____PERSONAL CHECK

_____VISA   _____MASTERCARD      CARD NUMBER________________________________
_____DISCOVER_____NOVUS______AMERICAN EXPRESS
SIGNATURE____________________________ EXPIRATION DATE______________________

SHIP TO ADDRESS:

BILLING ADDRESS (IF DIFFERENT THAN SHIPPING):

NAME___________________________
STREET__________________________
CITY_____________STATE___ ZIP CODE_______
COUNTRY________________________
DAY PHONE_______________________
EVENING PHONE___________________
FAX NUMBER_____________________

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