MrVitaHerbs Mail Order Form

Item Number	Product Description	Qty	Item Price	Total Price
			Sub-Total
	If orders are below $40 add $4.95 for Shipping/Handling		Shipping/Handling
	No Tax Required		Tax	0.00
			Grand Total

Shipping Address: Name: ___________________________________________________

Address: _________________________________________________

City, State, & Zip: ___________________________________________

Phone Number: ____________________________________________

E-Mail: ___________________________________________________

Billing Address: (Only needed if different from shipping address!)

Name: ___________________________________________________

Address: _________________________________________________

City, State, & Zip: ___________________________________________

Payment Methods:

Cashier or Certified Check (Personal checks not accepted): ___ Money Order: ___ Credit Card:___

(Make Cashier, Certified Check or Money Order payable to Alan Mowery dba MrVitaHerbs)

Credit Card: Visa ___ MasterCard ___ AMEX ___ Discover ___

Credit Card Number: ________________________________________

Exp. Date: __________ Card Security Code*: ________

* For your safety and security, MrVitaHerbs Merchant Services requires that you enter your card's verification number. The verification number is a 3-digit number printed on the back of your card. It appears after and to the right of your card number. If you have an AMEX card the verification number is as four digit number on the front and to the right of your card.

Reminders:

After fully completing this form please mail to:

MrVitaHerbs Inc.

1621 Cohasset Drive

Cincinnati, Ohio 45255

To complete your order we need a valid email address and phone number.

Your information is secure!

If you are interested in a FREE MEMBERSHIP your order must be $40.00 or more (excluding taxes and shipping) then Call Toll Free: 1-877-883-8313 to redeem free membership.

If you are interested in a part-time or full-time income call us at 1-877-883-8313 and we can show you how!!