Mr. Ms. Mrs. Dr. *First Name:   MI:     *Last Name:

BILLING ADDRESS:

*Street Address1:     Apt. #:

*Street Address2:      Country:

*City:     *ST:     *Zip Code:

*Telephone: (ex. 999-999-9999) Required for credit card orders and if we have questions about your order.

Payment Type: Visa    Master Card    Check Enclosed (for Mail in orders only)

Credit Card Number: (no hyphens ex. 1234567812345678)      3-or 4-digit security code:

Card Expiration Date:

SHIPPING ADDRESS (Fill in if different from above):

Street Address1:     Apt. #:

Street Address2:      Country:

City:     ST:     Zip Code:

E-Mail Address: (name@website.com)

Do you want to receive (infrequent) updates of new products, information, etc.?  Yes No
By: E-Mail Snail Mail  Both 

Please send me the following items: (ex. 2/Large/Peppermint-Spearmint/Bars/$5.00 each)

Shipping Preference: US Postal Service  UPS  Best Price  Other

Shipping Time:  Ground  Overnight  2-Day

Do you want to know the final cost of your order, including shipping & applicable tax before shipping?
Yes  No        If Yes, Via:  Telephone  or  E-Mail   

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