First Name: Last Name: Address: City: State:
Zip: Country: Email: Daytime Phone: Order Date: Consultant Name: (My name must be provided in order for me to get credit for the sale).
ITEM NO: QTY: ITEM NAME: PRICE EA: ITEM TOTAL:
Check Money Order.
Credit Card Number:
Expiration Date (MM/YY):
Name as it appears on card:
Send Checks or Money Orders to: Amparo Quiroz P.O. Box 11111 Bakersfield CA, 93253
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