Order Form

1) Please print out this order form and fill in all required information.

2) Make Check/Money Order Payable to John Coppa and mail to:

Smart Casino Gambling

P.O. Box 5472

Wakefield, R.I. 02880

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#1 One Card

Please fill in your choice of Smart Card

_______________________ $3.95

S/H---------------------------- 2.00

Total---------------------------$5.95

R.I. residents add 7% sales tax (R.I. total $6.23)

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3) Please Ship My Order To:

Name_______________________________

Address______________________________

City_______________State_____Zip_______

Phone / E-Mail ________________________

Please tell us how you found John Coppa's web site?

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