|
Please
print and fill out this form completely and fax it to: (866) 657-3163
|
|
10 WEEK SUPPLY |
SlimShot
x 5 boxes - $40 Savings |
$159.99 |
|
8 WEEK SUPPLY |
SlimShot
x 4 boxes -$20 Savings |
$129.99 |
| |
6 WEEK SUPPLY |
SlimShot
x 3 boxes -$15 Savings |
$104.99 |
| |
4 WEEK SUPPLY |
SlimShot
x 2 boxes -$5 Savings |
$74.98 |
| |
2 WEEK SUPPLY |
SlimShot x 1 box |
$39.99 |
|
|
|
Shipping
Information:
Name: |
|
Address: |
|
City/State/Zip: |
|
Country: |
|
Telephone: |
|
Email
Address: |
|
|
|
|
Amount
Enclosed:
Write
in the amount for the SlimShot supply you chose: |
$ |
Shipping
and Handling: |
$
|
TOTAL
ORDER IN US DOLLARS: |
$ |
|
|
Amount Enclosed
Type
of Credit Card: |
|
|
Visa |
|
Mastercard |
|
Discover |
|
American
Express |
|
Credit
Card Number: |
|
Expiration
Date: |
_______Month
_______Year |
Security
Code:
(3 or 4 digit number on back of card) |
|
Signature: |
|
|
|
|