Herbals, Inc.
 
9782 W. Mississippi AVE. LAKEWOOD, CO. 80226
Phone: 303-988-7685    FAX 303-980-1861
E-mail: herbalsinc@aol.com

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DATE_____________________            
ORDERED BY:         NAME___________________________________________

STREET_________________________________________

CITY___________________ STATE______ ZIP___________

PHONE_(_____)__________________________________

E-MAIL ADDRESS:________________________________ 


SHIP TO:      (Must have physical address)
NAME__________________________________________

STREET________________________________________

CITY____________________ STATE______ ZIP_________

PHONE_(_____)_________________________________

 

QTY

ITEM #

NAME/DESCRIPTION

UNIT PRICE

UNIT SIZE

TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Merchandise Total

 

Sales Tax (Colo. Residents)

 

Shipping (see terms)

 

TOTAL

 

 

 

 

Payment Options:        Circle One:     MASTERCARD     VISA                        Comments:

CARD NUMBER_______________________________________________
CARD EXPIRATION DATE_________________

Name on card_________________________________________________

Signature_____________________________________________________
FOR CHECKS:
Driver’s License #____________________________________State_____________