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: ____________________________________________