Your
Name  _______________________________________________________Deliver to: Street Address_____________________________________________________ Street Address_____________________________________________________ Floor, Suite, Apt. # _________________________________________________City _______________________
State ________________ Zip ______________Contact Phone # __________________________________ Email ___________________________________________ |
|
Quantity
|
Sub-total
|
Shipping
|
Total
|
MD
Residents Only*
|
|
 |
1
bottle @ $19.95
|
$19.95
|
+
$4.95
|
=
$24.90
|
Total
= $25.90
|
|
|
2
bottles @ $18.95
|
$37.90
|
+
$4.95
|
=
$42.85
|
Total
= $44.75
|
|
|
3
bottles @ $17.95
|
$53.85
|
+
$4.95
|
=
$58.80
|
Total
= $61.50
|
Choose payment method:
Check _________ Money Order_________ VISA _________ MASTERCARD _________
Amount Paid: $_______________ (Make checks payable to Charlotte Laboratories)
Name on Account:____________________________ Signature:____________________________
CC#: ______________________________ Expiration Date: ____________
Billing Address:____________________________________________________________________
| (leave blank if same as delivery address) |
Please include this
form, along with your payment, and mail to:
Charlotte
Laboratories
P.O. Box 34030
Bethesda, MD 20827
Inquire about our professional courtesies: Please
call 1-800-745-7343 or email info@aminaproducts.com
Thank You for your order!
Please allow 2-4 weeks for delivery.
This product is not intended to diagnose, treat, cure, or prevent any disease. Indicated use is covered by US Patents #5,789,443 and #6,245,812.