1. Please fill-in form. 2. Print form 3. Fax/Mail Order Form
TO:
NATURAL RX LABS
16161 VENTURA BL., #725, ENCINO, CA 91436
FAX NUMBER: (818)276-1845


NATURAL RX LABS FAX/MAIL ORDER FORM
Order Information
Select Product
CA Residents 9.25% Tax
Shipping 5.99 (If you order 4 Bottle Set + Free Shipping)
Optional: Rushing
Processing $1.50 		$1.50 (Check box if desired)
Optional: USPS
Priority Shipping $9.95 		$9.95 (Check box if desired)
Total Amount Billed
Credit Card Information
Credit Card
Card Number
Exp. Date  (mm / yy)
CVV Number
Customer Credit Card Billing Information
First Name
Last Name
Company
Address
City
State/Province
Zip Code
Phone
Fax
E-Mail
Customer Shipping Information (IF DIFFERENT FROM BILLING ADDRESS)
First Name
Last Name
Company
Address
City
State/Province
Zip Code
Checks/Money Orders Bank requires processing. Before shipping.