Learn To Quit Kit Order
Form
Fax Your Order To: 360.546.5681 |
|
Billing
Address |
For
your security, we verify all credit cards to the
billing address. This address must match the address
on your credit card statement if you are paying by
credit card. |
Shipping
Address |
Leave
the shipping address blank if it is the same as the
billing address. |
Name ______________________________
Address ___________________ Apt _____
City _____________ State ___ Zip _______
Daytime Phone _______________________
Email Address _______________________ |
Name ______________________________
Address ___________________ Apt _____
City _____________ State ___ Zip _______ |
Kindly send me
__________(quantity) Learn to Quit Kit(s) WITHOUT Telephone
Counseling @ $89.00 per Kit
plus an additional $7.00 per Kit to cover shipping
(NOTE: $89.00 + $7..00 s/h = $96.00 per
kit ordered)
CIRCLE
CHOICE:
CD's
or
Cassettes
Kindly send me
__________(quantity) Learn to Quit Kit(s) WITH Telephone
Counseling @ $89.00 per Kit
plus an additional $7.00 per Kit to cover shipping (NOTE:
$129.00 + $7..00 s/h = $136.00 per
kit ordered)
CIRCLE
CHOICE:
CD's
or
Cassettes
ORDER TOTAL
$________________
O Check
O Money Order
O VISA O MasterCard
O AMEX
Credit
Card Account Number
|
Exp.
Date
|
Cardholder
Signature (required) ___________________________
Print
then Fax to 360-546-5681 OR Mail to Address Below
|
