INSTRUCTIONS: Simply type required information into the boxes. No information will be sent over the Internet during this process. Print this page and mail in with your order.

Single Bottles are $24.95 Each
FREE Shipping to the USA

Limited Time Offer! Order 3 bottles and save almost $5.00
Total Cost for 3 Bottles = $69.99

QUANTITY

NAME AND SHIPPING INFORMATION
(Shipping Address Must Match Credit Card Billing Address)

CREDIT CARD INFORMATION
You may also phone in your credit card order.

Type of Credit Card - Please circle one
Name exactly as it appears on card
Card Number
Security Code (CVV2) Visa, MC, Discover - located on back AMEX - located on front				3 or 4 Digit # on Card Why? To verify you are in possession of the card.
Expiration Date of Card		Month Year
Signature		___________________________________________________________

SHIPPING TERMS

All shipments made via USPS mail
Fast deliver time - 3 days or less!

FREE SHIPPING (in the USA)

Credit card orders will be processed and shipped when received.

Cashier's checks and postal money orders will ship when received.

(Please allow 5 business days for personal checks to clear before shipment is released.)

MAIL THIS FORM TO

SYNFLEX USA
934 Main Street
Clifton Park, NY 12065

Questions? E-mail customerservice@synflexusa.com

THANK YOU FOR YOUR ORDER!