EZorb Online Fax/Mail Order Form

1. Fill out this form online and automatically calculate your order total.

2. Print out the completed form or write down on paper.

3. Fax it in or mail in with money order/bank draft/check.

Fax: 1-714-908-7264

Make money order/bank draft/check payable to Elixir Industry

For U.S. Only

An Easy Form is also available for your convenience.

Name:

Address:

Address (continue):

City:

State:

Zip:

Phone Number:

Email:

(Optional)

Payment Type:

Credit Card Check/Money Order

Cardholder Name:

Card Number:

Expires:

3-4 Digit Code:

Change quantity then press the Calculate button to obtain total amount.

Discounts Automatically Calculated on Combined Quantity of EZorb Powder & EZorb Capsules

7% off on orders of 3 to 5 bottles, 12% off for 6 or more bottles and 18% off for 12 bottles or more.

PRODUCT

QTY

PRICE

TOTAL

EZorb Powder 100G/BTL

$36.95

EZorb Capsules 180/BTL

$39.95

Marvlix Capsules 120/BTL

$37.95

Subtotal   

=

Discount   

=

Shipping   

$6.95

GRAND TOTAL   

Be sure to click the Calculate button before printing.

Mail completed form with checks to Elixir Industry, PO Box 8819, Brea, CA 92822-5819, USA