Prime Life Herbals - Mail Fax Order Form

Prime Life Herbals Mail / Fax Order Form
*Print this page, fill out all information, and send this form by mail or fax to:

Prime Life Nutriceuticals
165 Castilian Dr
Goleta, CA 93117

FAX: 805-681-8201

Customer Information

Name:
Address:

City:
State:	Zip:
Country:
Phone:
Email:

Payment Method

Select one
	Money Order / Cashiers Check (Payable to Prime Life Nutriceuticals in US$ only)
	Visa / MasterCard / American Express (circle one)
	Credit Card Number:
	Expiration Date:	/ Signature: _________________________

List Products
Please list items and prices as an example in the frist line.

Qty.

Product Name

Price

Cutis Vita - Buy 2 Get 1 FREE (this is an example)

Subtotal:

Shipping (US orders $9.95, international orders $24.95)

Grand Total:

Mail Order Form to:

Prime Life Nutriceuticals
165 Castilian Dr
Goleta, CA 93117

or Fax This Form to:

805-681-8201