Healing Touch by Serve the Goddess Fax Form

 

FAX TO: 323-935-5196

Size   Product Name  Quantity

  Amount

   Total
         
         
         
         
         
         
         
         
         
         
         
         
         
  FLAT RATE SHIPPING & HANDLING:  add  $4.05

 4.05
 

Total $

 
Name (AS IT APPEARS ON CARD)
Credit Card Type

oVisa  oMasterCard  oAmericanEx    oDiscover
Card Number _ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _
Expiry Date Month (............)   Year (............)
C V V Number (3 digit number on the back of your card)  
E-mail Address  
Full BILLING Address ------->
 

 

 

Full SHIPPING Address ----->

  

 

 
 
 

 

 
Signature as on card:
 X..............................................................
 
Print This Form print now

 

 

 

 

 

 

 

 

 

 

 
 

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