theFlexBelt®

Fax Order Form (US ONLY)
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Please print and fill out this form completely and fax it to: (310) 362-0582

 
4 FlexBelts® -  SAVE $150  (FREE SHIPPING**) $649.99
 
3 FlexBelts® -  SAVE $100   $499.99
 
2 FlexBelts® -  SAVE $50 $349.00
 
1 FlexBelt® $199.99
Shipping Information:
Name:
 
Address:
 
City/State/Zip:
 
Telephone:
 
Email Address:
 
Amount Enclosed:
Write in the amount for the number of theFlexBelts you chose:
$

Shipping and Handling:
 $16.95 Priority  2-4 business days
 $39.95 Express 1-2 business days

$
TOTAL ORDER IN US DOLLARS:
$


Payment Details
:

Type of Credit Card:
 
Visa
 
Mastercard
 
Discover
 
American Express
Credit Card Number:
Expiration Date:
_______Month      _______Year
Security Code:
(3 or 4 digit number on back of card)
Signature: