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To order by Telephone, call: |
Or mail it to: New Life Vision, LLC 1616 W. Cape Coral Parkway #231 Cape Coral, FL, 33914 |
___ Enclosed is my money order for $
*Shipping charges are as follows by country:
United States: $15 International: $40
Charge my: ___Visa
___Mastercard ___American
Express ___Discover
(Note: You can use more than one card to complete
this
order)
Card Number: ____________________________
Exp. Date: _____________________
CSV Code (3-digit security code on the back of the card): ______________
Amount $_____________
| Complete this section if using a second card to complete this order |
|
Second Card Type and Number. (if needed): ______________________________________ Second Card CSV Code (3-digit security code on the back of the card): ______________ Second Card Exp. Date: ____________ Amount $______________ |
Signature: __________________________________________
Print Name: _________________________________________
Address: ____________________________________________
City: ________________________ State: _____________ Zip Code:
____________
Country: ____________________________________________
Date of Birth: ______________________________________
Telephone: ________________________ Fax Number: ________________________
E-Mail: _____________________________________________