( no shipping charge · 2016. 5. 11. · published 04082016 iri ( no shipping charge place your...
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( NO SHIPPING CHARGE
Place your supply orders through our website, email or fax. www.richwayandfujibio.com- [email protected]
CUSTOMER INFORMATION .Q. INDEPENDENT SALES ASSOCIATE SUPPLY ORDER FORM [Please type or pr1nt legibly.]
Email address Name (Last) (first) {Middle lnltli I I I Contact Telephone Number with Area Coda
'It( ) I I Shipping Address (Street Nurrmer, Name, Apt NLnberl If a Cl8dlt C8ld Is ~. mlera must be shipped ID 1he cartllolder
City State
oDooD -DDDD .Q. D Free dellvary Is 1br the domesltc USA only.
Cirt:la the language you would liks to raquast below. ORDER INFORMATION "Avaiable in these languages: En~i&h (E), Spanish (S), French (F), Gennan (G), Chilese (C), Japanese (J~ Korean (K), Po~ (P}
rTEMNUMBER MATERIAL LANGUAGE PRICE QUANT11'Y AMOUNT 1000-001-E BIOMAT<» 7000MX BROCHURE E $20FOR20 1000-002-E BID MAT® 7000MX FLYER E $2DFOR4D 1000-003-E BID MAT® 7000MX USER MANUAL !CARTOON] E $20FOR2D
1 000-004-E/S/F/G/C/J/K/P FOURTH TREATMENT BOOK E,S, F, G, C,J, K. P $10FOR10 1000-005-EIG PRIME JOURNAL EJJ/C, G/K/5 $20 FOR 10 2501-002-E BIOBELT"'' 7000MX FLYER E $20FOR40 3010-001-E AMETHYST PILLOW BROCHURE E $20FOR2D 3010-002-E AMETHYST PILLOW FLYER E $20FOR40 7000-001-E QUANTUM ENERGY PAD• BROCHURE E $20FOR20 6010-001-E QUANTUM ENERGY COMFORTER"TN BROCHURE E $20FOR20 5070-001-E ALKAL-LIFETN 7000sL BROCHURE E $20FOR20 5070-002-E ALKAL-LIFETN 7000sL FLYER E $20FOR40 5070-003-E ALKAL-LIFETN 7000sL DVD E $5EACH 5000-004-E HEALING WATERS BOOK E $15.95 EACH 4303-002-E DETOXI™ FLYER E $20FOR40 8010-001-E REJUVENA114 7000 BROCHURE E $20FOR20 8012-002-E RICHWAY AMETHYST HYDROGEL FACE MASKTM FLYER E $20FOR40 0001-001-E ORDER FORMS E $20FOR50 0002-001-E ISAAGREEMENT FORMS E $20FOR50 0003-001-E COMPENSATION PLAN BROCHURE E $20FOR20
Choose from different languages. Avalable for purchase In spec/lied sets only. Call the Rlchway Ofllce for lntamatlonal shipping Information. To eliminate unn8C81181Y delays, Rlchway suggests the fcllowfng: Con1llate the form carefully and fellow alllns1nldlons. Review the form for emn before sanding It to the company.
Complete the following If billing addraaa Is different from shipping addraaa Sub-total Cardholder Billing Address:
Sales Tax '1.)
City State ~eDDDDD-DDDD Total Payment Due
CREDIT CARD PAYMENT
Credit card Number 4 0 Visa/MC 0 Amax 0 Discover 00thers( ) Expiration Date Approval Code
DODD· DDDD·ODDD·DDDD --'--Cardholder Name: Authorized Signature:
Independent Sales Associate's SI$J'Iature: ---------------- Date:
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