Print and mail this form to:
Larry P. Key, Nationally Certified Reflexologist
3927 W. 21st Place
Panama City, FL 32405
Please make checks payable to Larry P. Key
Fax credit card orders to: 1-555-123-4567
Address (No P.O. boxes please): _____________________________________
City: _______________________ State: ________ Zip: ___________
Daytime Telephone (please include area code): ____________________
|Roller~Flex (patent pending)||$ 15.00||$|
|The Genesis Factor 100% Colostrum||$ 35.00||$|
|Toner "The Juice"||$ 45.00||$|
|Metabolizer 2000||$ 35.00||$|
|Natural Herbal Sleep Aid||$ 20.00||$|
|St. John's Wort with Ginkgo Biloba||$25.00||$|
|Super MSM||$ 25.00||$|
|Osteo Tek Liquid Calcium Complex||$25.00||$|
If paying by credit card, please enter your card number below:
(Circle One) VISA | MasterCard
Card No.: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
Expiration date (MM/YY): ___________ Name on card: ____________________________
Billing Address: __________________________________________________________
By signing below, I authorize Larry P. Key to charge my credit card the amount listed as the "Grand Total" on this order form.
Authorized signature of account holder
Please be advised that orders paid by personal check will not be shipped until your check is cleared. This takes 7-10 days and means that it could be up to 2 weeks before you receive your order. Sorry, but we cannot accept CODs at this time.
Additional Shipping Information
UPS 2nd Day, add $10.00 to shipping amount. (850) 522-1705; Email: email@example.com
UPS Next Day, add $15.00 to each of the above amounts.
Hawaii and Puerto Rico must be shipped UPS 2nd day.
Email us about international rates.
(850) 522-1705; Email: firstname.lastname@example.org