Wellness Trader, LLC
13011 W. U.S. Highway 42, Suite 010, Prospect, KY 40059

Fax Order Form

Please Print this form, then fill out, using a dark pen.
Fax the completed form to
502-228-7893
You may telephone your order 1-800-969-7228
You may mail your order using this form: http://www.wellnesstrader.com/forms/mail-order-form.html

First Name: Last Name:
Phone Number: Email Address:
Credit Card Type: Visa __ Mastercard __ American Express __ Discover __
Credit Card #: Expiration date (month, year):
Signature:
Street Address (where credit card is billed):
City: State or Province:
Country: Zip:

Shipping Address (if different from above):
City: State:
Country: Zip:

Qty. Product Description Size Unit Price Extended
Price
         
         
         
         
         
         
         
         
         
Sales Tax 6% (Kentucky Residence):  
(SHIPPING: Flat Fee: $5.00 UPS Ground) Shipping:
(Post Office and APO addresses will be shipped via USPS.) 		  
Total:  

Thank you for your order!