If you prefer not to order online using paypal or your credit card
please print this form, complete, and fax to: (419) 517-0757
To order by telephone, please call (347) 731-9013
Please allow 7 to 10 days for shipping.
Items Ordered:
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Price |
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Plus 8.25% sales tax (NY residents only) |
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Shipping & Handling |
3.95 |
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Total |
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For more items, please print and include a second form.
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Customer Information
*First Name ________________________
*Last Name ________________________
Company ________________________
*Email ________________________
Phone _________________________
Credit Card Information
*Card Type ________________________
*Cardholder’s Name As Shown On Card ___________________________________
*Card Number ______________________
*Expiration Date (mmyy) ____ / ____
*3 Digit Security Code _______________
*Required fields. |
Billing Address
*Address Line 1 ______________________
*City _______________________________
*State/Province _______________________
*Country _____________________________
*Zip/Postal Code ______________________
Shipping Address (if different from billing address)
Ship To Name __________________________
Address Line 1 __________________________
City __________________________________
State/Province __________________________
Country _______________________________
Zip/Postal Code _________________________
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Thank you for ordering from Hair Growth Essentials. If you have any questions, please do not hesitate to contact us by phone at: (347) 731-9013, or by email at: hairgrowthessentials@earthlink.net .
