|
Please
print and fill out this form completely and fax it to: (888)-610-5761
|
| |
4 MONTH SUPPLY |
Vialipro
x 4 boxes -$200 Savings |
$179.99 |
|
3 MONTH SUPPLY |
Vialipro
x 3 boxes -$10 Savings |
$139.99 |
| |
2 MONTH SUPPLY |
Vialipro
x 2 boxes -$5 Savings |
$94.99 |
| |
1 MONTH SUPPLY |
Vialipro x 1 box |
$49.99 |
|
|
|
Shipping
Information:
Name: |
|
Address: |
|
City/State/Zip: |
|
Country: |
|
Telephone: |
|
Email
Address: |
|
|
|
|
Amount
Enclosed:
Write
in the amount for the Vialipro 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: |
|
|
|
|