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Canadian Residents
To receive your free 3 gram sample packet of Intimé Personal Lubricant
complete this form, and mail it back to us along with two postage stamps.

American Residents
To receive your free 3 gram sample packet of Intimé Personal Lubricant complete
this form and mail it back to us. Enclose $1.00 dollar for international postage.


Please Print Clearly
Please note: we do not accept personal cheques.

Name:
 __________________
Street address:
 __________________
Apt:
 __________________
City:
 __________________
Prov:
 __________________
Postal code:
 __________________
Email Address: __________________

Molco Cosmetics Corp.
Jackson Square Postal Stn.
2 King St. W., Box # 57082
Hamilton, Ontario (Canada)
L8P 4W9

To ensure receipt of your free sample all forms must be
complete and postage enclosed. Allow two weeks for delivery.