Fax Order Page

Fax Order Page - FemElle
Check this box to print a blank form

Fax completed form to:
954-241-6979

SHIPPING INFORMATION

First and Last Name:
Street Address 1:
Street Address 2:
City:		State/Province:
Zip Code:		Country:
Email Address:		Phone Number:

QUANTITIES - Enter quantities and the form will calculate your total

Qty

SKU

Item Name

Price

Subtotal

FML-CA3

FemElle Sex Drive Enhancer 3 Month Supply

$89.95

$0.00

FML-CA2

FemElle Sex Drive Enhancer 2 Month Supply

$74.95

$0.00

FML-CA1

FemElle Sex Drive Enhancer 1 Month Supply

$39.95

$0.00

SHIPPING - Order over $159.00 receive free ground shipping

UPS Ground Shipping - $7.95	UPS Next Day Air - $22.95
UPS to Canada (CANADA ONLY) - $14.95	USPS International - $19.95
UPS 3-Day Select - $9.95	UPS 2nd Day Air - $12.95

UPS Ground Shipping - $0.00	UPS Next Day Air - $22.95
UPS to Canada (CANADA ONLY) - $14.95	USPS International - $19.95
UPS 3-Day Select - $9.95	UPS 2nd Day Air - $12.95

Subtotal:

$0.00

Shipping:

$0.00

Total:

0.00

Fax completed form to: 954-241-6979

PAYMENT DETAILS

If you are paying by credit card, please fill in the required information below:

Card Number:

Card Expiration Date (MM/YY):

CVV2 Number:

Name as it appears on card:

Credit Card Street Address:

Credit Card City, State:

Credit Card Country:

Credit Card Zip Code:

Cardholder Signature:

Please select the credit card type used for this order:

MasterCard

Visa

American Express

Discover Card

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