INTERNATIONAL BATTERY TECHNOLOGIES

FAX NUMBER 303 530 7178

TO       INTERNATIONAL BATTERY TECHNOLOGIES

FROM        NAME_______________________________                                     DATE_________________         YOUR REFERENCE   NUMBER__________________

                STREET ADDRESS________________________________

                CITY______________________________________________

                STATE_______________________________      ZIP_______________

PHONE NUMBER__________     ___________   ____________

CREDIT CARD     TYPE        NUMBER                                     EXPIRATION DATE

                            ______     _______________________             ____________

PRODUCT ORDER

        PRODUCT NAME         MODEL NUMBER            PRICE     QTY          TOTAL PRICE

    ________________          _______________      ______   ____         _____________

    ________________          _______________      ______   ____         _____________   

      ________________          _______________      ______   ____        _____________    

   ________________          _______________      ______   ____        _____________                                                                            

    SUB-TOTAL                      ______________       ______   ____         ______________                                                            

SHIPPING CHOICE (CIRCLE ONE)

    2 TO 4 DAY                                                 $    6.50

    2ND DAY                                                     $ 11.50

    NEXT DAY                                                  $   17.50                 ________________

TOTAL                                                                                         ________________

SIGNATURE_________________________________________