FREEDOMYOU.COM  P.O. Box 42  Cannington, ON, CANADA  L0E 1E0

This form is for Canadian orders only!

Print this form and mail with a cheque or money order.
Make cheques payable to Freedomyou.com.

(Please Print Clearly)

DATE _______________________________


NAME __________________________________________________________________________________


STREET ADDRESS _______________________________________________________________________


                                    _______________________________________________________________________


CITY ________________________________________________  PROVINCE  ________________________


POSTAL CODE_____________________________________   COUNTRY ___________________________


TELEPHONE ________________________________________  


EMAIL (please print clearly)  _______________________________________________________________