|
| Item No. | Description | Qty | Price | Total Price |
|
Shipping Charges |
Special Instructions |
|
|
| $00.00 to $24.99 add $5.50 |
Merchandise Total: |
||
| $25.00 to $34.99 add $7.50 |
|
||
| $35.00 to $44.99 add $8.50 |
CA add 7.75% Sales Tax: |
||
| $45.00 to $54.99 add $9.50 |
|
||
| $55.00 to $74.99 add $11.50 |
Shipping (See chart): |
||
| $75.00 to $99.99 add $12.50 |
|
||
| $100.00 & up add $15.50 |
Total Amount: |
| Billing Information | Payment Method | Shipping Information |
| Name |
 Check
Money
Order |
Name |
| Address |
Money Order and Checks are for Mail Orders only. Please allow an additional week for personal checks to clear. |
Address |
| City |
Visa
Mastercard
|
City |
| State and Zip |
American
Express |
State and Zip |
| Daytime Phone |
Discover
|
Today's Date |
| Card Number | Customer Service: | Elumessence |
| Expiration Date | 1-800-301-8512 | 9332 Champs De Elysses |
| Signature | Fax: (707) 887-9275 | Forestville, CA 95436 |