~ LIGHTER ORDER FORM ~

Please print and fill out the following form. If you do not have a printer, you may simply write down the necessary info. Please note that all orders are non-refundable.

Please note that disposable lighters are classified as hazardous materials and must be shipped by ground. YOUR ADDRESS MUST ACCEPT U.P.S. DELIVERY. No Post Office boxes, etc.

Name: __________________________________________________________

Address for UPS Delivery: ______________________________________

City, State, Zip: ______________________________________________

Phone Number (Optional): _______________________________________

E-Mail Address (Optional): _____________________________________


         Lighter Color               Total                 Total
          Combination                 Num.                 Cost


Mixed VARIETY PACK                   _____   x   $20   =   _____

Green on WHITE                       _____   x   $20   =   _____

Green on YELLOW                      _____   x   $20   =   _____

Yellow on GREEN                      _____   x   $20   =   _____

                      Total Number:  _____    Total Cost:  _____

Make your check payable to LEGALIZE and mail it along with the above order form to: