Inquiry and Order Form

To ask for more information, conveniently place your Avon or Fuller Brush order, or request services or information from the Passion of Life Ministries, Inc., Thoughtful Moment or Employees Assistance Program, please fill out this form.

E-Mail with your replies if you can't use forms: ScharlauSR@aol.com

Thanks for your interest. I will be in touch with you soon.- Dave Scharlau

Please be sure to enter your correct e-mail address so I can easily contact you.

Your Name:

Mailing Address:

City: State:

Zip Code: Country:

Phone:

E-mail Address:

URL (web address if available):

1. What is your interest? (check all that apply)

: purchase an Avon product

: purchase a Fuller Brush product
: become a distributor

: interested in services/info for Thoughtful Moment

: interested in services/info for Passion for Life Ministries, Inc.

: interested in services/info for Employees Assistance Program, Inc.

: more information (see below)

2. Please type in the items you would like to order or your question. When contacted, we can discuss specifics:

3. How did you find my web site?

: Google

: Yahoo!

: Excite

: Alta Vista

: Hot Bot

: InfoSeek

: AOL

: MSN.com

: EMOL.org (Entertainment Magazine) or AZentertain.com

: Other:

Any specific questions or needs that you have or general comments? Thank you!

Thank you for your feedback. You only need to click the send button once.

If you have a problem with this form, please e-mail me at ScharlauSR@aol.com