American Longevity On-Line Orders......Taken here!

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Street:
City:
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ZIP:
Tel:
Fax:
E-Mail:
	(Order confirmation will be sent to you here.)

Code
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Merchandise Total:
7.25% Sales Tax: (California Residents Only)
Shipping/UPS Reg.ground :
Proceessing fee (7%)-$4.50 minimum
Total:

Payment Via: Credit Card Number: Expiration Date:

Instructions for: International Shipments

Comments:

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that appears above, or any questions or comments
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AUTHORIZED

American Longevity Distributor
For personal service Call:
Craig Walcott ID#3501
Telephone1-719-488-2080
ORDER HOT LINE : 1-800-787-5508
e-mail:

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