GREAT WALL HERBAL LIMITED
MAIL & FAX ORDER FORM

GREAT WALL HERBAL LTD.
333 Stewart Avenue
Victoria, BC, Canada
V9B-1R6
Fax: 250-383-3730

 

CONTACT INFORMATION

 

Company Name (if applicable):

 

Contact Name:

 

Phone Number:

 

Fax Number:

 

E-mail Address:

 

 

MAILING ADDRESS

 

Street Address:

 

Apartment # :

 

City:

 

Zip or Postal Code:

 

Country:

 

 

CREDIT CARD INFORMATION

 

Credit Card Type & Number:

 

Expiry Date: (mo/yr):

 

Name on Credit Card:

 

Street Address:

 

Apartment # :

 

City: 

 

Zip or Postal Code:

 

Country:

 

* * All address information must be completed if cardholder name is different than the above information.  Name and address information should be exactly the same as on the credit card statements.

 

YOUR ORDER--PLEASE SPECIFY WHAT FORMULA                    (All sales are calculated in US dollars)

 

 

Product

TYPE & Qty

Price

Total

1 Month Supply

 

X 49.95

= $

2 Month Supply

 

X 89.95

= $

3 Month Supply

 

X 125.95

= $

Shipping & Handling

Wordwide:       $ 7.00
(up to 3 bottles, additional bottles $0.50 each)

Sub-Total:

$

+ Shipping:

$

+ Tax:

$

TOTAL:

$

 

Cheques Made Payable To:

Great Wall Herbal Ltd.

Mail this order form to the address above, or fax to 250-383-3730

 

Print This Page