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ReliantSkincare.com
sales@reliantskincare.com
Fax orders to: 201-599-0212
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Name
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Address 1
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Address 2
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City, State Zip
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Phone & Fax
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Email
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Quantity
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Product
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Price
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Sub Total
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Shipping/Handling (see chart below)
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Sales Tax (Deliveries to NJ Only) 7%
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Total
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Up to $9.99
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$5.95
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$10.00 - $49.99
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$7.95
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$50.00 - $99.99
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$9.95
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$100.00 - $199.99
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$11.95
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$200.00 and up
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$13.95
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Please note - shipping charges shown are for US deliveries only.
For international orders, please contact us for correct shipping charges.
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Name on Card
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Card Number
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Expiration Date
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3 Digit Security Number on Back of Card
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Billing Address
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Signature_________________________________________D ate___________________
Print and Fax this completed form to 201-599-0212 to place your order
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