Synergy For Life Mail / Fax Order Form

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Synergy For Life Mail/Fax Order Form
Print out this page, fill in the details and fax to (360) 351-6618
or Mail to: Synergy For Life, PO Box 5962, Winston-Salem, NC 27113-5962
For information or to place an order by telephone call toll-free:
(888) 311-2963

Billing Address

NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MAILING ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CITY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

STATE . . . . . . . . .. . . . . . . . . . . . ZIP. . . . . . . . . . . . . . . . . . . .

PHONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

E-MAIL ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Shipping Address (if different from billing address)

NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

STREET ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

STATE . . . . . . . . . . . . . . . . . . . . . . . . . ZIP. . . . . . . . . . . . .

SPECIAL HANDLING INSTRUCTIONS . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Your Order
Item Name / Description	Quantity	x Unit Price	=Total Price




SIGNATURE X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .DATE. . . . . . . . . . . . . . . . . . . . .

Shipping Options

Please see our shipping information page

International orders please email us for shipping fee quotes

Method of Payment

To speed your order, please include check, account, or credit card information.

Check enclosed (U.S. ONLY)

Credit Card

Visa

Mastercard

AMEX

Discover

Account #

___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___

Exp. Date:______/______

Sub Total	$______________
Shipping	$______________
TOTAL AMOUNT	$______________
FAX to 360-351-6618 or Mail to: Synergy For Life P.O. Box 5962 Winston-Salem, NC 27113-5962
NOTE: Orders paid by personal or business check will be held until funds have cleared. Orders paid by money order, cashier check or other guaranteed funds will be processed and shipped the following business day.

FAX to (360) 351-6618

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