Quality Service Co.
Dept. HS
P. O. Box 667
Elmira, NY 14902
United States of America
NOTE: IF YOU DON'T HAVE A PRINTER, BUT WISH TO MAIL US YOUR ORDER, SIMPLY WRITE THE INFORMATION ON A PIECE OF PAPER.

| Sizes | Quantity | Cost Ea. | Total |
| (One 3 ounce Jar) Small | $19.95 | ||
| (One 6 ounce Jar) Medium | $29.95 | ||
| (2 Jars = 9 ounces) Large | $39.95 | ||
| (2 Jars = 12 ounces) X-Large | $47.95 |
| Name: | ______________________________________ |
| Address: | ______________________________________ |
| City: | _______________State:____________Zip:__________ |
| Country: | ______________________________________ |
For credit card orders:
Type:______________________
No._________________________________
Exp. Date:__________________