~ Please Print This Form, Complete, and Mail or Fax Order ~
Billing Information
Payment Method: |
Make Payable To: |
Mail or Fax To: |
| Check [ ] Money Order [ ] Credit Card [ ] |
Harbor Laboratories |
Harbor Laboratories |
Credit Card Orders: | ||
Credit Card Type: [ ] VISA [ ] MasterCard [ ] Discover | ||
Account #: ______-______-______-______ | Exp. Date: ___/___ (Month/Year) | |
Signature: ________________________________ | ||
MIRAKELLE Order Information
Restorative Eye
CremeGel (1.12 oz.) |
$ __________ |
|
$ __________ |
SUBTOTAL: |
.............................. |
$ __________ |
SALES TAX: |
.. (MA Residents Add 5%) |
$ __________ |
SHIPPING & HANDLING: |
...................... (Add) |
$ 4.95 |
TOTAL: |
.............................. |
$ __________ |
Shipping Information
Name: ______________________________________ |
Address: ______________________________________ |
City: ______________________ State/Province: ________ Zip/Postal Code: ________ |
Phone: Area Code (____) Number _____-________ |
Thank You!
www.MIRAKELLE.com
Harbor Laboratories, Inc., Duxbury, MA
info@mirakelle.com
1-800-334-0667
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Modified: October 6, 2008 |
Webmaster: dawnsweb.net |