Mail Order Form - Smokers Rescue System© SHIP TO: Name: _________________________ Street Address:___________________________ City: _______________________ State: _____________ Zip Code:____________ (Province): ______________ (Country): _________________ Phone (optional): _________________ Email (optional):_____________________ Smokers Rescue System© Quantity:
____ X Price: $44.95 = Subtotal: $_________
USPS Priority Mail (USA Only)1 unit = $7.00 2 units = $11.00 3 or more = $15.00 Worldwide (Airmail Post) 1 unit = $14.00 2 units = $21.00 3 units maximum = $26.00 Add Shipping: $_________
Sales Tax (Iowa residents only .06) $_________ Order Total: $_________ SunBurst Smokers Rescue 807 East Pearl Street #3 Decorah, Iowa 52101 with Check or MO for Order Total Thank You Customer Service 1-888-338-7909 To pay by Credit Card: Visa __ Mastercard __ Amex __ Discover __ Cardholders name: ________________________ Card number: __________________________________ Exp date (mo/yr): ________ CVC code on back (3 or 4 digits): ____________ Order Total: $______________ Your signature: __________________________ |