If you prefer
to fax your order then 
Print
this page and send this form to the above number.
Millennium Health LLc
Fax
Order Form
USA
fax 208-361-0460
-- 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
|
$ 7.95 | ||
|
Total
|
|||
|
All fields must be filled in for order to
be processed 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 / Amex only: 4 digits on the front-right of the card above the main numbers) Card type (Visa/Master/Etc.) ____________ Expiry Date___________ US$_________ Card holder billing address if different from above, otherwise leave blank: _____________________________________________ _____________________________________________
_____________________________________________ |
|
Fax
the complete form to 208-361-0460
Your payment receipt and order confirmation will be sent to your email address Thank you for your custom! |