Fax Order Form

Internet Order Processing
660 Baker Street, Suite 350
Costa Mesa, CA 92626 USA
Phone:866 468-7739

CREDIT CARD FAX ORDER FORM
For fax orders, complete this order form, print it out and fax it to:

714-432-7116
If pay by check please don't forget to include your Check number here:

Name and Credit Card Information	Qty	Select Product
Name:
Address 1:
Address 2:
City:
State/Prov:
Zip Code:
Country:
Phone:
E-Mail:
Credit Card:
Card No:
Name on Card:
Exp. Date:

For Single Tests Buy At Least 3 In Any Combination For Best Price


Buy 1-2 at $2.40 each	Buy 3-4 at $2.35 each	Buy 5-8 at $2.30 each	Buy 9-12 at $2.25 each

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