(Form best printed with size 12 fixed pitch, e.g. Courier, font
with 1/2 inch [0.5"] margins and no page header or footer)

ENVIRO-MED                    800-222-DAWN (Toll-Free)
1600 SE 141ST AVE             360-256-6989 (Direct)
VANCOUVER, WA  98683          360-260-8095 (FAX)

biolight@bio-light.com (E-Mail)
http://www.bio-light.com/ (WWW web site)

ORDER FORM
(Prices subject to change without notice)

 QTY               ITEM                 PRICE      TOTAL
=====  ============================  ========  =========
_____  BIO-LIGHT ULTRA 10,000  . . .  $299.00  _________
_____  Acrylic Stand . . . . . . . .  $ 16.00  _________
_____  Carrying Case . . . . . . . .  $ 46.00  _________

_____  BIO-LIGHT SOLAR DELUXE  . . .  $420.00  _________
_____  Floor/Desk Stand  . . . . . .  $ 65.00  _________
_____  BIO-LIGHT SOLAR DELUXE with
         Floor/Desk Stand (save $10)  $475.00  _________
_____  Acrylic Stand . . . . . . . .  $ 16.00  _________
_____  Carrying Case . . . . . . . .  $ 46.00  _________
_____  BIO-LIGHT EXECUTIVE . . . . .  $399.00  _________
_____  Carrying Case . . . . . . . .  $ 46.00  _________
_____  Winter Blues Book . . . . . .  $ 15.95  _________

              Total for Merchandise  . . . . . _________
        WA residents 7.6% Sales Tax  . . . . . _________
       Shipping charges (see chart)  . . . . . _________

                              TOTAL  . . . . . _________

Shipping Charges per Bio-Light:
          Oregon and Washington  $15
               U.S. (48 states)  $25
                Alaska & Hawaii  $35
		           Book  $ 4

Your shipping address (No P.O. boxes)

       NAME:____________________________________________
    ADDRESS:____________________________________________
            ____________________________________________
CITY, STATE:____________________________________________
   ZIP CODE:____________________________________________

      PHONE:____________________________________________
        FAX:____________________________________________
     E-MAIL:____________________________________________

  Paying by: __Check  __Money Order  __VISA/Mastercard

VISA/Mastercard information:

   VISA/Mastercard #:___________________________________
     Expiration date:___________________________________
Name printed on card:___________________________________
Cardholder signature:___________________________________