Order Form for Pancreas Tonic

Herbalenium
382 N. Lemon Ave. #220
Walnut, CA 91789 U.S.A
Email: Herbalenium

Order by Phone
(10am - 7pm PST)
1-626-963-4220

Order by Fax *
1-626-963-4498

*please include: your name, full mailing address, phone number,
Number of Bottles, $4.95 ( plus $2.00 for each additional Bottle) shipping & handling,
credit card type, account number, and expiration date.
Thank You

Pancreas Tonic

Description	Quantity	Price	Total
Pancreas Tonic
Sub-Total:
Sales Tax: 8.25% California
Shipping & Handling $4.95 Regular Mail $15.00 Express U.S. ONLY Mail Plus $2.00 Per additional bottle (included in calculation)
Total (US Dollars)

Billing Information

Please fill out the following section as completely as possible.

Name: First:	Mi: Last:
Organization:
Phone Number:	Fax number:
Address:
City:	State: Zip Code:
Country:
E-mail:

If ordering to or from a country other than the United States of America, please include country code, city code, and number in the phone number blanks.

Accepted Credit Cards
visa
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Name on Credit Card:
Credit Card Number:
Expiration Date:
If using a credit card make sure the billing address for the card is entered in the Billing Information section above as the credit card company has it.