Hair Energizer Vitamins - Printer Friendly Order Form

Hair Stimulator Order Form
Printer Form for Mail Order  or Order Online
Customer Name:
Address:
City: State: Zip:
Day Phone: Eve. Phone: Fax: E-mail:
Qty Item Description Price Total
  1a  Hair Stimulator vitamins 1 bottle $9.95  
2a Hair Stimulator vitamins 2 bottles $17.90
3a Hair Stimulator vitamins 3 bottles $23.95
4a Faster Growing hair Kit (Shampoo, conditioner & vitamins) $21.95
5a Emu shampoo 32oz $20.95
6a Emu conditioner  32oz $20.95
7a 8oz each Emu Combo (shampoo and conditioner) $15.95
8a 8oz Retinex shampoo $12.95
9a Retinex vitamin 1 bottle $19.95
10a Retinex Combo (Shampoo & vitamins) $29.95
11a Antifungal Cream $14.95
12a Pro K for Spider Veins $23.95
13a 16oz  each Royal Jelly Shampoo & Conditioner $23.95
14a Royal Jelly DMAE Cream $29.95
15a Royal Jelly Capsules $24.95
  16a Weight Loss Stimulator Fat Burner $14.95  
17a Weight Loss Stimulator Carb Blocker $14.95
SUBTOTAL:  
SALES TAX:
 		  $0.00
SHIPPING (USA ONLY): $5.95
TOTAL AMOUNT:

 

PAYMENT INFORMATION
PAYMENT TYPE:* (Please select one.) No Cash or C.O.D. accepted. money order payments accepted
  Credit Card     Money Order
** Make checks payable to: Hairstimulator

CREDIT CARD PAYMENT INFORMATION:
TYPE OF CARD:*
  Visa   MasterCard   American Express
CARD NUMBER:* (Must be 16 digits) EXP. DATE*
    |    |    |    |    |    |    |    |    |    |    |    |    |    |    |    |
CARDHOLDER'S NAME AS IT APPEARS ON THE CARD:*
 
CARDHOLDER'S SIGNATURE:* (Orders can not be processed without signature)