ESTROTHIN WHOLESALE ORDER FORM

Estrothin Wholesale
165 Castilian Dr
Goleta, CA  93117
FAX: 805-681-8201
Phone: 800-282-8709

 ** For orders outside US, please contact us

1.

Billing Information
Please enter your billing information exactly as it appears on your credit card statement.

Name:

 ______________________________________________________________

Company:

 ______________________________________________________________

Address:

 ______________________________________________________________
Address2: ______________________________________________________________

City:

 ______________________________________________________________

State:

_________________________ Zip: ____________________________

Country:

 _________________________

Phone:

 _________________________ Fax: ____________________________

Email:

 ________________________________________________________

2.

Payment Method upon the reciept of payment, your order will be processed.

Select one

Money Order / Cashiers Check (Payable to Prime Life Nutriceuticals in US$ only)

Visa / MasterCard / American Express (circle one)
 

Credit Card Number:
 

Expiration Date:

/

Card Holder's  Signature:: _____________________________________
3.

Shipping Information if different from above :

Name:

 ______________________________________________________________

Company:

 ______________________________________________________________

Address:

 ______________________________________________________________
Address2: ______________________________________________________________

City:

 ______________________________________________________________

State:

_________________________ Zip: ____________________________

Country:

 _________________________

Phone:

 _________________________ Fax: ____________________________          

Products are shipped via UPS Ground. Contact us for other shipping method.

4.

Select Products s

Packaging:
In 1 oz. amber glass boston rounds, glass dropper, and black cap and bulb, neck band shrink seal. 12 per case and 144 per master case.

ESTROTHIN 1 bottle - 1 oz. (30 days supply)
24 bottles of Estrothin
$550.80
36 bottles of Estrothin
$790.20
72 bottles of Estrothin
$1508.40
144 bottles of Estrothin
$2728.80
Over 144
Contact us

Sub Total:

$.
Shipping & Handling :
Shipped UPS Ground.
$20.00  
Total:
$.


Signature : ______________________________ Date: _______________