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Offline Order Form (Please print, complete and return to us) |
| Billing Info: | |
| Name: | _____________________________________ |
| Address: | _____________________________________ |
| City, State & Zip: | _____________________________________ |
| Country: | _____________________________________ |
| Phone Number: | _____________________________________ |
| Email Address: | _____________________________________ |
| Shipping Info: | |
| Name: | _____________________________________ |
| Address: | _____________________________________ |
| City, State & Zip: | _____________________________________ |
| Country: | _____________________________________ |
Product Order |
QTY
|
Unit Price
|
Shipping & Handling
|
Total
|
| 1 Bottle Of Colvera™ |
$49.95
|
$4.95 |
||
| 3 Bottles Of Colvera™ (Save $29.90) |
$119.95
|
$7.95 |
||
| 5 Bottles Of Colvera™ (Save $59.80) |
$189.95
|
$9.95 |
||
|
|
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|
Total Price: |
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| ___ Credit Card ___ Money Order ___ Check (Personal Checks take 2 weeks to process) |
| Credit
Card Information: ** Please note that charges will appear on your card as - Health10.com - ** |
| Visa MasterCard Discover |
| Credit Card Number: ________ - ________ - ________ - ________ Exp. Date: _____ / _____ |
| Signature______________________________________ |
|
Please mail this form to: Health10.com, Inc. Or fax it to: 1-253-669-9961 Make checks & money orders payable to - Health10.com, Inc. - If you have questions, please call us toll free at 1-888-393-9079 or email us at sales@health10.com |