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EnergyPlates.com 15508 W Bell Rd Ste 101-438 Surprise,
Arizona 85374
Phone: 1-877-877-0747 Fax 1-623-321-9977
E-Mail:
(Please Print)
See **Payment Method Below**
Name (as it appears on the credit card) | ||
Address Line 1 | ||
Address Line 2 (optional) | ||
City | State/Prov./Prefecture | Postal Code |
Country (if not USA) | ||
E-mail Address (needed for order confirmation) | Home
Phone ( ) |
Office
Phone ( ) |
Credit Card Number with Security Code | Card (Visa, MC, Discover, Amex, Diners, Carte Blanche, JCB) | Expiration Date |
Name of Recipient (if different, optional) | ||
Shipping Address (if different, optional) | ||
Shipping Address Line 2 (if different, optional) | ||
City | State/Prov./Prefecture | Postal Code |
Country (if not USA) |
For a complete pre-printed order form CLICK HERE!
Item | Description | Quantity | Unit Price | Subtotal |
Comments:
|
TOTAL: |
Shipping and Handling |
||||
USA |
International Shipping will be determined by Weight and Country at time of shipment. Please e-mail for final shipping charges. |
Thank you
|
**PAYMENT METHOD**
Payment will only be accepted made
out to Scot Brown.
Please pay amount due in cash, check, or money order.
International orders payable in US Funds preferred
as a Money Order from your Post Office.
International Money Order also accepted. Please follow above note.