Swiss Corrective Skin Care

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	Order Form
	SHIPPING INFORMATION Name: _________________________ Address: _________________________ _________________________ City/State: _________________________ Zip/Country: _________________________ Telephone: _________________________ E-Mail: _________________________ (in case we need to contact you)	BILLING INFORMATION Name: _________________________ Address: _________________________ _________________________ City/State: _________________________ Zip/Country: _________________________ Payment Method: [ ]Bank Check (check one) [ ]Money Order [ ]AMEX [ ]Visa [ ]Master Card
	Card Number: ________________________ Exp Date: ________________________ Signature: ________________________ (make checks payable to Swiss Corrective Skin Care) -------------------------------------------------------------------------------- ITEM / DESCRIPTION QUANTITY COST TOTAL ____________________________________________ __________ __________ __________ ____________________________________________ __________ __________ __________ ____________________________________________ __________ __________ __________ ____________________________________________ __________ __________ __________ ____________________________________________ __________ __________ __________ ____________________________________________ __________ __________ __________ SHIPPING 5-day Ground @ $6.99 2-day Air @ $10.00 International Standard Air @$10.99 first item (add $1.00 for each additional item): __________ Sales Tax: __________ FINAL TOTAL: __________ FAX completed orders to (818)-763-4660 Mail completed orders to Swiss Corrective Skin Care, P.O.Box 3881 Beverly Hills, Ca. 90212 USA Mail in your Bank Check or Money Order.