Order Form for C·answer 3XM

Herbalenium
382 N. Lemon Ave. #220
Walnut, CA 91789 U.S.A
Email: Herbalenium

To Order by Phone
(10am - 7pm PST)
1-626-963-4220

To Order by Fax *
1-626-963-4498

*please include: your name, full mailing address, phone number,
Number of Bottles (Quantity), $4.95 ( plus $2.00 for each additional Bottle) shipping & handling,
credit card type, account number, and expiration date.
Thank You

C·answer 3XM

Regular Suggested Retail Price is $99.95 per bottle - Our Special Internet Price is $79.95 per bottle - A $20 Savings!

Description	Quantity	Price	Total
C·answer 3XM
Sub-Total:
Sales Tax: 8.25% California
Shipping & Handling $4.95 Priority Mail $15.00 Express U.S. ONLY Mail Plus $2.00 Per additional bottle (included in calculation)
Total (US Dollars)

Billing Information

Please fill out the following section as completely as possible.

Name: First:	Mi: Last:
Organization:
Phone Number:	Fax number:
Address:
City:	State: Zip Code:
Country:
E-mail:

If ordering to or from a country other than the United States of America, please include country code, city code, and number in the phone number blanks.

Accepted Credit Cards
visa
Visa MasterCard American Express Discover

Name on Credit Card:
Credit Card Number:
Expiration Date:
If using a credit card make sure the billing address for the card is entered in the Billing Information section above as the credit card company has it.