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Date:

______________________________________________________________

Name:

______________________________________________________________

Address:

______________________________________________________________

City:

______________________________________________________________

State:

______________________________________________________________

Zip Code:

______________________________________________________________

Phone Number

______________________________________________________________

Email Address:
_____________________________________________________
________________

Requested Amount of Dinar: (EXAMPLE: 500,000 Dinar): ______________________


Enclosed USD Amount (Including 10% Handling/ Processing Fee): ________________
[EXAMPLE: 500,000 Dinar = $500 + $50 (10% Fee) = $550 USD]

Honoring of Purchase: If we have received your certified check before the Revaluation of the
Iraqi Dinar, your order will be honored. If the RV has occurred before we have received your
certified check, the certified check will be returned to you.

The information provided above allows us to know where to send the Dinar and who to send the
confirmation email to. Please print clearly to allow us to process your order more efficiently.