Chinese Natural Herbs - Fax Order Form

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: ______________________________________   *Exp. Date: ____________

Product ID:           Name of Product                                                                     Quantity:

1.______________    ______________________________________________________     ___________

2.______________    ______________________________________________________     ___________

3.______________    ______________________________________________________     ___________

4.______________    ______________________________________________________     ___________

5. ______________   ______________________________________________________     ___________

Special Instructions:____________________________________________________________________

____________________________________________________________________________________

We will email you a confirmation after we have received your fax.

For international orders, we will provide shipping options and rates and give you a grand total for your order.
By placing an order, you understand and accept all risks associated with shipping overseas and that the
customer is responsible if your package is rejected by Customs Inspections.

Fax the completed order form to our Temporary Fax#: 215-238-9640. You may also mail this completed form to:

Chinese Natural Herbs
1011 Arch St
Philadelphia, PA 19107 USA