Simply print and fill out the form below and fax to 1.818.758.7504
First Name:
Last Name:
Address:
City:
State:
Zip:
Phone:
Email:
Please print out this order form and mail it to the address on top. Please include your Check or Money Order.
Item Code
Description
Price
Quantity
JP001
1 Month (120 tablets)
$25.95
JP002
3 Months (360 tablets)
$65.85
JP003
6 Months (720 tablets)
$120.70
Name as on Card
CC# Street Address
CC# City
CC# State
CC# Zip
We will never automatically ship any more of our products to you or ever bill your credit card again unless you personally reorder.
Please select your shipping cost below:
USA Shipment - $5.95
Credit Card Number _________________________________________
Expiration Date _________________________________________
Signature: _________________________________________
(cardholder signature)