(PLEASE COMPLETE FROM AND SHIP TO ADDRESS IN LEGIBLE WRITING, OTHERWISE IT MAY DELAY ORDER)

After completion fax to  831-722-9947

FROM:

SHIP TO:

DELIVERY PHONE NUMBER:

PHONE NUMBER:

(If sending to multiple addresses please

FAX NUMBER:

attach additional sheets)

ITEM

Item Ordered

QTY.

TOTAL PRICE

LEMON CYPRESS LOTION

$9.10

LAVENDER LOTION

$9.10

ROSEMARY LOTION

$9.10

ALL 6.2 OZ. 176 G

SHIPPING AND HANDLING

Depends

CHARGES PER 1 LOTION

on your

Location

Please note:  There will be a $10.00 additional charge for each incorrect address and zip code.

Subtotal

Freight

Total Amount Payable

PAYMENT BY:

(  ) MASTERCARD

(  ) VISA

3 Digit #

(on the back of the card)

CARD NUMBER:

CARDHOLDER NAME:

CARDHOLDER SIGNATURE:

EXP. DATE:

AMOUNT:

DATE:

IF PAYING BY MASTERCARD OR VISA PLEASE SIGN AND FAX BACK TO (831)722-9947.

PURCHASE WILL BE CHARGED TO YOUR CARD AT TIME OF SHIPPING