GO CYBER SHOP! Citywide Solutions Inc. 253 King Street North, Unit #22 Waterloo, Ontario Canada N2J 4V2 Phone: 519-884-5545 THIS FORM MUST BE PRINTED AND SENT WITH YOUR PAYMENT Failure to send this form may result in refusal of order! ______________________________________________________________________ Product: SKU#12C508 - PlayStation - Stealth IV Modchip Prewired Price: $8.45 Quantity: 2 Weight: 0.02 lbs Quantity x Price: $16.90 ______________________________________________________________________ SUB TOTAL: $16.90 Repeat Customer Savings: $1.69 NEW SUB TOTAL: $15.21 Shipping Regular Airmail Shipping to United States: $2.00 GST Included: 0.00 (not applicable) PST Included: 0.00 (not applicable) GRAND TOTAL: $17.21 Payment by: Prepayment ______________________________________________________________________ Name: John Moses, soccerboy1111@yahoo.com Address: 3525 N. Marwin City: Springfield Province/State: MO Country: United States Zip/Postal Code: 65803 Phone: 4178335784 Work Phone: Age: 17 Users IP: 67.165.144.125 I have read and agree to the return & shipping policies. ______________________________________________________________________