ViacremeDelight.com
Postal 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 |
| Viacreme (1 pillow pack) | $9.95 | ||
| Viacreme (3 pillow packs) | $24.95 | ||
| Viacreme (6 pillow packs) | $39.95 | ||
| Viacreme (12 pillow packs) | $69.95 | ||
| Escalate Cream (30 ml pump container) |
$29.95 |
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| Other: |
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Sub Total: |
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Shipping: |
$0.00 |
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Sales Tax: |
$0.00 |
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Total Price: |
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| Payment Information: |
| ___ Credit Card ___ Personal Check ___ Money Order ___ Cash |
| Credit Card Information: |
| __ Visa __ MC __ AMEX __ Discover |
| Credit Card Number:_____________________ Exp. Date: _______ |
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