
FAX ORDER FORM
*Required fields
Billing Information:
*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