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
Name: _____________________________________________________
Address (No P.O. boxes please):
_____________________________________
City: _______________________ State: ________ Zip:
___________
Daytime Telephone (please include area code):
____________________
| Item Name | Price | Qty. | TOTAL |
| 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 | $ | |
| ORDER SUBTOTAL: |
$ | ||
| SHIPPING | $ 6.00 | ||
| GRAND TOTAL: |
$ |
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: lkeykeyman@knology.net
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.
Larry P.Key