FAX ORDER FORM

*Required fields
Billing Information:
Your BILLING information MUST MATCH the information on file with your Credit Card Company.
 We will NOT be able to complete your order without a match!

*First Name: ________________________ MI: _______ *Last Name: ________________________________

Company: ___________________________________________________________________

*Street Address: ______________________________________________________________

*City __________________________________________________ *State _______________

*Zip Code:_____________________*Country ______________________________________

*Phone #: ______________________________ *Email Address: ____________________________________

Shipping Information: (If Different from Billing Information)

*First Name: ________________________ MI: _______ *Last Name: ________________________________

Company: ___________________________________________________________________

*Street Address: ______________________________________________________________

*City __________________________________________________ *State _______________

*Zip Code:_____________________*Country ______________________________________

*Phone #: ______________________________ *Email Address: ____________________________________

Credit Card Information:

*Name as it appears on card: __________________________________________________

*Card Type: (VISA, Mastercard, Amex, Discover) __________________________________

*CVC Number (Last 3 digits on back of Visa, Mastercard or Discover Card): _____________

*Card Number: ____________________________________________________________

*Expiration Date: ___________________________________________________________

Product ID:           Name of Product                                                                     Quantity:

1.______________    ______________________________________________________     ___________

2.______________    ______________________________________________________     ___________

3.______________    ______________________________________________________     ___________

4.______________    ______________________________________________________     ___________

5. ______________   ______________________________________________________     ___________

Special Instructions:____________________________________________________________________

____________________________________________________________________________________

Fax the completed order form to 610-358-0372.  You  may also mail this completed form to:

Chinese Natural Herbs
1011 Arch St
Philadelphia, PA  19107 USA