Free Electricity Order Form

First/Last Name:

Home Phone:

Work Phone:

Other Phone:

Email Address:

Please type your information in the spaces below. Fields in red are required.

Physical Address (place where unit would be installed; PO Box not permitted)

Street:

Apartment No:

City:

State/Province:

Country:

Zip/Postal Code:

Mailing Address (if different from physical address)

Street:

Apartment No:

City:

State/Province:

Country:

Zip/Postal Code:

     Please send me the "Free Energy" DVD for just $19.95 (includes S&H). I understand that by purchasing this DVD I will be automatically registered for Free Electricity and will receive official confirmation of my registration in the mail which will detail the requirement to attend a public demonstration of ITEC's energy technology when notified as to time and place.

     I wish only to register without purchasing the DVD. Included is $7.50 for S&H.

Payment by:  CheckCashMoney Order

Please print completed form and mail with payment in U.S. funds to:

TechKnowLogic Devices

PMB #221

5820 W. Peoria Ave. Suite 107

Glendale, AZ  85302-1301

After printing the completed form please hit the "Submit" button to let us know you will be mailing it in.

(817-333-5555)

(817-333-5555 or 817-333-555x12345)

(817-333-6666 cell)

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