ProAnagen Mail Order Form

Please print this form, then fillout your order and mail it to us.

Product Name	**Unit Price	QTY	Total
3-Month Supply:• 1X 3-Month ProAnagen™ Topical Solution: 3 bottles of 2 Oz. solution	$69
3-Month Supply: 1X Shampoo: 3 bottles of 2 Oz. solution and 1X Shampoo	$74
6-Month Supply, 2X Shampoo: 6 bottles of 2 Oz. solution, and 2X 8 Oz. ProAnagen™ Shampoo	$132
12-Month Supply, 4X Shampoo: 12 bottles of 2 Oz. Solution and 4X 8 Oz. ProAnagen™ Shampoo	$242
1 X 8 OZ. ProAnagen Shampoo	$17.99
2 X 8 OZ. ProAnagen Shampoo	$35.50
---	---
1 X 8 OZ. ProAnagen™ Conditioner	$16.99
2 X 8 OZ. ProAnagen™ Conditioner	$33.50
---	---
1 X 2 OZ. Shampoo & Conditioner Sample Do not order, if ordering Reg. Shampoo & Conditioner	$3.50	1	.
Sub Total
Colorado Residents: Please add 2.9% Sales Tax

Shipping & Handling Charges
Standard Shipping	Orders Less than $69	Orders $69 or More
U.S.	$7	$7
Canada/Mexico	$25	$25 (Up to 3 Lb./1.4 Kg.)
Europe	$25	$25 (Up to 3 Lb./1.4 Kg.)
Australia/New Zealand	$25	$25 (Up to 3 Lb./1.4 Kg.)
Please verify prices at www.proanagen.com			TOTAL

Customer Shipping Information
Name
Address 1
Address 2
City & State
Zip Code
Phone
E-mail
Please tell us how did you heard about us:

Credit card billing information: Please enter the information exactly as it appears on your credit card statement.

First Name
Last Name
Credit Type (Please circle)	Visa/Master Card/Amex/Discover
Card Number
Expiration Date:	____/____
3 Digit Security (4 for Amex)
Billing Address 1
Billing Address 1
City
State
Zip Code
Home Telephone (Optional)
Date of Order
Signature

Payment Methods Accepted:
Major credit cards, cashier's
Check/Money Order or personal
check (subject to funds clearing)

Our Mailing Address:
ProAnagen™
P.O. Box 3248
Englewood, CO 80155-3248