Mail In Order Form

Name ________________________________________________

Address_______________________________________________

City/State/Zip__________________________________________

Daytime Phone_________________________________________

(if different from above:)

Ship To _______________________________________________

City/State/Zip __________________________________________
 Check or Money Order enclosed in US$ drawn on a U.S. bank, payable to Truth Coins.
 Please charge my credit card:_____________________________  (Signature)
 VISA    Master Card      AMEX     Discover                      

Card # _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _          Exp. Date mo/yr _ _/ _ _ _ _

Card Verification Number _____  

 Name on Card: __________________________________________

                                                                       Quant.       Price

1st Coin ________________________         _____      ________

2nd Coin ________________________        _____      ________

3rd Coin ________________________        _____      ________

4th Coin ________________________        _____      ________

Shipping & Handling                     + ________

                                                  Sub Total      _____     ________

Ohio residents add 6.75% sales tax                             + ________

                                                Grand Total                   ________

Form TC-OF 04/06