Velvet Order Form

Velvet Orders

Please print this order form, complete it and fax it to us.

Ordered By:
Ship To:

Name: Name

# Road/Street:
UPS requires the above # Road/Street:
UPS requires the above

Mailing Address: Mailing Address:

City/Town/Zip City/Town/Zip

State or Province: State or Province:

Country: Country:

Telephone: Telephone:

E-mail: E-mail:

QTY PRICE TOTAL PRICE

30 capsules (2 btl. min.) $36.20

60 capsules $35.00

90 capsules $51.00

120 capsules $65.00

150 capsules $79.00

200 capsules $104.00

500 capsules $275.00

1000 capsules $510.00

Shipping and Handling: (USA:$4.00, International:$6.00)

Ordered By:	Ship To:
Name:	Name
# Road/Street: UPS requires the above	# Road/Street: UPS requires the above
Mailing Address:	Mailing Address:
City/Town/Zip	City/Town/Zip
State or Province:	State or Province:
Country:	Country:
Telephone:	Telephone:
E-mail:	E-mail:

	QTY	PRICE	TOTAL PRICE
30 capsules (2 btl. min.)		$36.20
60 capsules		$35.00
90 capsules		$51.00
120 capsules		$65.00
150 capsules		$79.00
200 capsules		$104.00
500 capsules		$275.00
1000 capsules		$510.00