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.