Mail Order Page

Mail Order Page - Nicrx
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Print & mail with payment to:
Health Formula
398 E. Dania Beach Blvd #400
Dania Beach, FL 33004

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

NIC-1

Nicrx: 1 Month Supply

$49.95

$0.00

NIC-3

Nicrx: 3 Month Supply

$124.95

$0.00

NIC-6

Nicrx: 6 Month Supply

$199.95

$0.00

SHIPPING

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

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

Subtotal:

$0.00

Shipping:

$0.00

Total:

0.00

Mail in US Dollars, Cashier Checks or Money Orders payable to: "Health Formula".

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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