Golden Pride, Vitamins Direct and W.T. Rawleigh Products - Mail Order Form

Name: ____________________________
Phone Number: ____________________________
Email Address: ____________________________
 
Shipping Address
Address: ____________________________
City, State Zip ____________________________
 
Billing Address (if different from shipping address)
Name: ____________________________
Address: ____________________________
City, State Zip: ____________________________
 
Product Quantity Unit Price Total Price
. . $ $
. . .

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Shipping:
$6.45 for your first pound, .50 cents for each additional pound
or call for a shipping quote 1-800-533-1395

$

Sub Total: 

 

Sales Tax In Your State: 

 

Grand Total: 

$
 

Payment Information: 

___ Personal Check (U.S. Only)    ___ Money Order (U.S. only)   

Credit Card_______________________ #   Expiration______________Date
last 3#s in the signature area _________________
 
Make your check or money order (U.S. only) payable to:
VITAMINS DIRECT

Mail your order to: Patricia Koch
P.O. Box 389
Crystal River, Florida 34423
UNITED STATES OF AMERICA

If you have any questions,
please call Patricia Koch toll-free 1-800-533-1395.