WellnessTrader.com

Fax Order Form

Please Print this form, then fill out, using a dark pen.
Fax the completed form to
505-228-7893

First Name: Last Name:
Phone Number: Email Address:
Credit Card Type: Visa __ Mastercard __ American Express __ Discover __
Credit Card #: Expiration date (month, year):
Signature:
Street Address (where credit card is billed):
City: State or Province:
Country: Zip:

Shipping Address (if different from above):
City: State:
Country: Zip:

Qty. Product Description Size Unit Price Extended
Price
         
         
         
         
         
         
         
         
         
Sales Tax 6% (Kentucky Residence):  
(SHIPPING: Flat Fee: $3.85 USPS Priority Mail) Shipping:  
Total:  

Thank you for your order!