FIRST NAME: __________________________________                                                   Power Grip
                                                                                            P.O. BOX 1 WYSOX, PA. 18854
                                                                                                         (570) 885-8213
LAST NAME :___________________________________

ADDRESS: _____________________________________

CITY:__________________________________________

STATE:_________________________________________

ZIP CODE:_______________________________________

PHONE NUMBER: _________________________________

E-MAIL ADDRESS: _________________________________
 PAYMENT METHOD - Make all payments payable to POWER  GRIP
P.O. BOX 1   WYSOX, Pa 18854

PRICE $29.95 per pair plus $4.00 shipping anywhere in the Continental USA including Alaska, Hawaii, and Puerto Rico. If you are ordering more than one pair, we will box them in one large package to save you on individual shipping charges. We will ship them UPS or US mail whichever is cheeper. E-mail us @ powergrip@hughes.net or call (570) 885-8213 for shipping charges on larger orders.
Money Order ______
CHECK___________
VISA #___________________________________EXPIRATION DATE - Month_______Year _______

MC # ____________________________________EXPIRATION DATE - Month__________Year _______
IN ORDER FOR YOUR POWER GRIPS TO FIT PROPERLY, WE NEED TO KNOW YOUR WRIST SIZE IN INCHES. Simply measure the circumference (AROUND) your wrist (in front of the wrist bone) with a measuring tape or a piece of string and check the appropriate box below.

Quantity___SIZE ___SMALL 6" to 6-1/2"

Quantity___SIZE___ SMALL PLUS 6-1/2" to 7"

Quantity___SIZE___ MEDIUM 7" to 7-1/2"

Quantity___SIZE___ MEDIUM PLUS 7-1/2" to 8"

Quantity___SIZE___ LARGE 8" to 8-1/2"

Quantity___SIZE___ SPECIAL ORDER SIZE If you don't see your wrist size listed above either larger or a smaller wrist size please write it down here_________ and we will custom make a pair of POWER GRIPS at no additional charge.
TOTAL AMOUNT - POWER GRIPS $_________________________
SHIPPING CHARGES $_____________________________________
TOTAL ENCLOSED $_______________________________________