theFlexBelt®

Fax Order Form (US ONLY)
Click HERE to PRINT THIS PAGE

Please print and fill out this form completely and fax it to: (505) 882-0334
 
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:
 $7.95 Standard  3-7 business days
 $11.95 Priority   2-3 business days
 $22.95 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: