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Please send form with payment or credit card information to:

D.S. Neil Enterprises
155 W. Willow
Pomona, CA 91768
Phone 1-800-4WALIWASH or (909) 865-2626

Name_________________________________________________________________

Address_______________________________________________________________

______________________________________________________________________

City___________________________________________________________________

State____________________________________ Zip___________________________

Telephone______________________________________________________________



For Master Card or Visa Orders, Please Fill In Below:

Credit Card No._________________________________________________________

Expiration Date_________________________________________________________

Signature______________________________________________________________



I Am Ordering _____________ (Number of Units) at $_________________________

For Each Unit, Add $14.95 For Shipping & Handling.

(California Residents Must Include Sales Tax.)

I Am Enclosing Check Money Order In The Amount Of $_________________