SIMPLY "FILL IN THE BLANKS" - Print and Fax to: 720-222-8789
Name:
Street:
City:
State:
ZIP:
Tel:
Fax:
E-Mail:
(Order confirmation will be sent to you here.)
Code
Product
Price
Qty
Extension
x
=
x
=
x
=
x
=
x
=
x
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Merchandise Total:
SALES TAX (FOR YOUR AREA):
Shipping/UPS Reg.ground :
Wholesale Status
Total:
Payment Via:
Credit Card Number and CVV#:
Exp. Date:
Comments:
Use this space to to indicate shipping to your office,
business, or other address different from the address
that appears above, or any questions or comments concerning your order.
Please note: Although it is most unlikely that you will experience any problems
responding to this form, certain non-standard browsers will not respond properly.
If you experience any difficulties, (or if you are not using a forms-capable browser)
you may email your response to this form to:
Debbie Allen.
If you have questions or need more information:
Call me at (800) 769-7923 (MST)
or
* These statements have not been evaluated by the Food and Drug Administration.
These products are not intended to diagnose, treat, cure, or prevent any disease.
