Fax order form

To order our Créme de Vie simply print out this form, complete in black ink, sign and fax to our offices.

Our fax number is +27.12.361 0061.

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anti-wrinkle, anti-aging, cream

FAX ORDER FORM
Surname 
Name  
Postal address  
   
   
   
Zip code  
Country  
Telephone number (Country code + area + number)
e-mail address (used to confirm dispatch)
Items required Item name Quantity Price 
(US Dollars)		 Total
   Créme de Vie   US $ 95.00   
   Postage  1 INCLUDED   US $ 0.00
    TOTAL TO BE BILLED  
Credit card details 
Credit card type (Specify Visa, MasterCard, Amex or Diners)
Card number                                
Expiry date Month then year    
CCV number Visa and MasterCard cards >          Amex cards >            
Your signature  
   
Special instructions and notes