|
PILLSEXPERT.COM
MAIL ORDER PAGE
|
||
| COMPLETE AND FAX THIS FORM TO -----> |
(866) 820-0638 (Toll-Free US Only)
+1-267-350-6523 (International) Your Authorization Code:
|
|
|
Check
Number Of Bottles
|
||
|
|
5 VIMAX
BOTTLES (SAVE $84.80)
|
PRICE:
$214.95 USD
|
|
|
4 VIMAX
BOTTLES (SAVE $49.85)
|
PRICE:
$189.95 USD
|
|
|
3 VIMAX
BOTTLES (SAVE $24.90)
|
PRICE:
$154.95 USD
|
|
|
2 VIMAX
BOTTLES (SAVE $9.95)
|
PRICE:
$109.95 USD
|
|
|
1 VIMAX
BOTTLE
|
PRICE:
$59.95 USD
|
|
Billing
Information
|
||
| Your
Name: (First/Middle/Last) |
||
| Billing Address: | ||
| City / State or Province / Zip: | ||
| Country | ||
| Telephone Number: | ||
| Email
Address: |
||
|
Shipping
Information (Ignore if the same as Billing Information)
|
||
| Shipping Address | ||
| City / State or Province / Zip: | ||
|
Payment
Details
|
||
| Credit Card : | ||
| Credit Card Number: | ||
| Exp Date (MONTH/YEAR): | / | |
| 3
or 4 Digit Security Code: |
Note: This can be found on the back of your credit card. It is followed right after your credit card number. | |
| Authorized Signature : | ||