GHR Gold - FAX In Order Form


Please click on the print icon above to print this form,
then enter the required information and fax to:


GHR Products

(877) 400-1110



SELECT QUANTITY BELOW:

  The following are pricing options for GHR Gold Non-Recurring Order (Ships once)

1 Month Supply (1 Bottle) $45.95

3 Month Supply (3 Bottles) $137.85

6 Month Supply (6 Bottles) $119.97

12 Month Supply (12 Bottles) 179.95

  The following are pricing options for GHR-15 Recurring Orders (Automatic shipments - Lower Prices - Cancel Anytime)

1 Month Supply (1 Bottle) $39.95 (ships once a month)

3 Month Supply (3 Bottles) $97.00(ships every 3 months)

6 Month Supply (6 Bottles) $159.95 (ships every 6 months)

12 Month Supply (12 Bottles) $269.40 (ships every 12 months)

California residents please add 8.25% sales tax.  All prices are in U.S. Dollars.

 

CUSTOMER BILLING INFORMATION

  FULL NAME:
____________________________________________________________
STREET ADDRESS: ____________________________________________________________
CITY, STATE, ZIP: ____________________________________________________________
COUNTRY/PROVINCE: ____________________________________________________________
TELEPHONE NUMBER: ____________________________________________________________
   
CUSTOMER SHIPPING INFORMATION (If different from billing)

  FULL NAME:
____________________________________________________________
STREET ADDRESS: ____________________________________________________________
CITY, STATE, ZIP: ____________________________________________________________
COUNTRY/PROVINCE: ____________________________________________________________
TELEPHONE NUMBER: ____________________________________________________________
   
PAYMENT INFORMATION
VISA MASTERCARD AMERICAN EXPRESS DISCOVER
NAME ON CARD: ____________________________________________________________
CARD NUMBER: ____________________________________________________________
EXPIRATION DATE: ____________________________________________________________

Your order will be shipped via USPS. If you wish to receive tracking information please be sure to include your email address.

AGE VERIFICATION

  I hereby certify that I am at least 18 years of age.

AUTHORIZATION

I authorize GHR Products to charge me for the above total. I further affirm that the name and personal information provided on this form are true and correct. I further declare that I have read, understand and accept GHR Products's business terms as published http://www.ghrproducts.com. By signing I agree to pay GHR Products.



  CUSTOMER SIGNATURE: ____________________________________________