GH3 gerovital h3 fax order form

Fax Order Form
USA fax 610-546-1964
-- Press "send" after the greeting message --

If you prefer to fax your order then Print this page and send this form to the above number.

Quantity	Product	Price	Subtotal
		$



1st Class Shipping and handling			$ 10.95
Total

All fields must be filled in for order to be processed
(BLOCK, capital letters please)

Name _________________________________________________________________

Address ________________________________________________________________

City ___________________________________________________________________

State _________________Postal/Zip ___________ Country _____________________

Telephone _________________________ Email _________________________

Credit Card Number _____________________________________________________

Card Verification Number ________ (For most cards: last 3 numbers on the back of the card)

Card type (Visa/Master only) ____________ Expiry Date___________ US$_________

Card holder billing address if different from above, otherwise leave blank:

_____________________________________________

_____________________________________________

Signature ______________________________ Print this page

Allow up to 5 - 7 days for delivery in the USA/Canada

Fax the complete form to 610-546-1964
Your payment receipt and order confirmation will be sent to your email address
Thank you for your custom!