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Please
print this form, then fillout your order and mail it to us. |
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Product
Name |
**Unit
Price |
QTY |
Total |
| 3-Month
Supply:• 1X 3-Month ProAnagen™ Topical Solution: 3 bottles
of 2 Oz. solution |
$69 |
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| 3-Month
Supply:
1X Shampoo:
3 bottles of 2 Oz. solution and 1X Shampoo |
$74 |
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| 6-Month
Supply, 2X Shampoo: 6 bottles of 2 Oz. solution, and 2X 8 Oz. ProAnagen™
Shampoo |
$132 |
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| 12-Month
Supply, 4X Shampoo: 12 bottles of 2 Oz. Solution and 4X 8 Oz. ProAnagen™
Shampoo |
$242 |
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| 1
X 8 OZ. ProAnagen Shampoo |
$17.99 |
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| 2
X 8 OZ. ProAnagen Shampoo |
$35.50 |
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| --- |
--- |
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| 1
X 8 OZ. ProAnagen™ Conditioner |
$16.99 |
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| 2
X 8 OZ. ProAnagen™ Conditioner |
$33.50 |
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| --- |
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| 1
X 2 OZ. Shampoo & Conditioner Sample Do
not order, if ordering Reg. Shampoo & Conditioner |
$3.50 |
1 |
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Sub
Total |
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Colorado
Residents: Please add 2.9% Sales Tax |
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Shipping & Handling Charges |
Standard
Shipping |
Orders
Less than $69 |
Orders
$69 or More |
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| U.S. |
$7 |
$7 |
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| Canada/Mexico |
$25 |
$25
(Up to 3 Lb./1.4 Kg.) |
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| Europe |
$25 |
$25
(Up to 3 Lb./1.4 Kg.) |
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| Australia/New
Zealand |
$25 |
$25
(Up to 3 Lb./1.4 Kg.) |
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Please verify prices at www.proanagen.com
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TOTAL |
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Customer
Shipping Information |
| Name |
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| Address
1 |
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| Address
2 |
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| City
& State |
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| Zip
Code |
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| Phone |
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| E-mail |
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Please
tell us how did
you heard about us: |
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Credit
card billing information: Please enter the information exactly
as it appears on your credit card statement. |
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| First
Name |
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| Last
Name |
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| Credit
Type (Please circle) |
Visa/Master
Card/Amex/Discover |
| Card
Number |
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| Expiration
Date: |
____/____ |
| 3
Digit Security (4 for Amex) |
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| Billing
Address 1 |
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| Billing
Address 1 |
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| City |
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| State |
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| Zip
Code |
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| Home
Telephone (Optional) |
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| Date
of Order |
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| Signature |
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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
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