Fax Order Form

Wholesale Supplement Store - FAX Order - 1.508.393.8435

Product: _________________---______-_ Quantity:

(name of the product you are ordering)

1) ___________________________ ----------- ____

2) ___________________________ ----------- ____

3) ___________________________ ------------____

4) ___________________________ ----------- ____

5) ___________________________ ------------____

Shipping Address:

Name: _____________________________

Address: ______________________________

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City: _____________________________

State/Province: _______________________

ZIP/Postal Code: ______________________

Country: ______________________________

Phone Number: _________________________

Billing Address: (leave blank if same as shipping address)

Name: _____________________________

Address: ______________________________

-------------- _______________________________

City: _____________________________

State/Province: ________________________

ZIP/Postal Code: ______________________

Country: ______________________________

Phone Number: _________________________

Credit Card:--- VISA --- Mastercard ---American Express ---Discover --- (circle the correct card)

Card Number: __________________________

Expiration Date: ___________

Name on Card (exactly as it appears): ____________________________

E-mail Address: (we will send you an order confirmation) ___________________________

Questions? Comments? -

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