EstroThin - Order Form

Mail / FAX Order Form
*Print this page, fill out all information, and send this form by mail or fax to:

Prime Life Nutriceuticals / Estrothin
165 Castilian Dr
Goleta, CA 93117

FAX: 805-681-8201

Customer Information

Name:
Address:

City:
State:	Zip:
Country:
Phone:
Email:

Payment Method

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:	/ Signature: _________________________

Select Products

	Buy 2 bottles of Estrothin Get 1 bottle Free (Three Month Supply )	$99.90
	Buy 3 bottles of Estrothin Get 2 bottles Free (five Month Supply )	$149.85
	Buy 5bottles of Estrothin Get 4 bottles Free (nine Month Supply )	$249.75
	Single bottle of Estrothin	$49.95
	Special Bonus Offer: Detoxify Advanced Cleansing & Weight Loss Formula (30-Day Supply)	$29.95

	Subtotal:	$.
	Subtotal:	$.
	Shipping (US orders $9.95, international orders $24.95)	$.
	Grand Total:	$.

Mail Order Form to: (make the check payable to Prime Life Nutriceuticals)

Prime Life Nutriceuticals / Estrothin
165 Castilian Dr
Goleta, CA 93117

or Fax This Form to:

805-681-8201