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


FAX: 310-822-0650

1.

Customer Information

Name:

Address:

City:

State:

 Zip:

Country:

Phone:

Email:
 

2.

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: _________________________

3.

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

Qty.

Product Name

Price
1

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

$
    5 9
9 0
s


$ssss.ss

ss

 

$ssss.ss
ss

 

$ssss.ss
s  

$ssss.ss
s  

$ssss.ss
s

 

$ssss.ss
box

 

$ssss.ss

Subtotal:

$ssss.ss

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

$ss.ss

Grand Total:

$ssss.sss

4.

 

Mail Order Form to:

Prime Life Nutriceuticals

or Fax This Form to:

310-822-0650