MotionEaze and DiVertigo

Printable Mail/FAX Order Form - FAX to: (credit card orders only) (419) 791-5295
Type in your name, address etc; print the form; and write in your order with a pen.


Only VISA, MASTERCARD AND AMERICAN EXPRESS ACCEPTED for mail-in and phone orders.

Is this an OVERNIGHT ORDER REQUEST please call
1-888-212-5503 or Internationally at 727-842-7544

Billing Address:

First Name:    Last Name:

Address:

               

City:   State:   Zip Code:   

Country:  

Telephone:   Email address:  


Shipping Address: (if different than billing address)

First Name:    Last Name:

Address:

               

City:   State:   Zip Code:   

Country:  

Telephone:   Email address:  

Items

QUANTITY

 

 COST EACH  

TOTAL

MotionEaze (5 ml. bottle)

  

X

 $15.95

=

  
DiVertigo (5 ml. bottle)  

X

 $19.95

=

  
   

 

  

 
SUB TOTAL      

 

  
SHIPPING AND HANDLING
INSIDE
THE UNITED STATES Only		   $3.00 (Standard S&H)
$6.00 (Priority)

 

  
OUTSIDE
THE UNITED STATES		   $6.00 (Standard S&H)
$12.00 (Priority)
    
TOTAL   FREE standard shipping on orders of three bottles or more!     

Make money orders/checks payable to "Alta Labs" in U.S. dollars. (No Eurochecks) Orders shipped upon arrival if made with a credit card, bank check or money order. Orders made with personal checks (US banks only) may be held until funds clear.

Credit Card Orders (only MasterCard, Visa, American Express accepted):
Note: The card billing address must be the same as the shipping address for verification purposes. Transactions will appear on your credit card bill as "Alta Labs".

Please be sure that your address information above is the same as it appears on your credit card statement.

Card holder name  Card number: 

Bank Verification Code on card:

Expiration date   

Customer signature ___________________________________


Please mail your order to:

Alta Labs
PO Box 427
Elfers, FL 34680
Or FAX to: (credit card orders only)
(419) 791-5295

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