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EnergyPlates.com • 15508 W Bell Rd Ste 101-438 • Surprise,
Arizona 85374
• Phone: 1-877-877-0747 • Fax 1-623-321-9977 •
• E-Mail:
•
(Please Print)
See **Payment Method Below**
| Name (as it appears on the credit card) | ||
| Address Line 1 | ||
| Address Line 2 (optional) | ||
| City | State/Prov./Prefecture | Postal Code |
| Country (if not USA) | ||
| E-mail Address (needed for order confirmation) | Home
Phone ( ) |
Office
Phone ( ) |
| Credit Card Number with Security Code | Card (Visa, MC, Discover, Amex, Diners, Carte Blanche, JCB) | Expiration Date |
| Name of Recipient (if different, optional) | ||
| Shipping Address (if different, optional) | ||
| Shipping Address Line 2 (if different, optional) | ||
| City | State/Prov./Prefecture | Postal Code |
| Country (if not USA) | ||
For a complete pre-printed order form CLICK HERE!
| Item | Description | Quantity | Unit Price | Subtotal |
|
Comments:
|
TOTAL: |
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Shipping and Handling |
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USA |
International Shipping will be determined by Weight and Country at time of shipment. Please e-mail for final shipping charges. |
Thank you
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**PAYMENT METHOD**
Payment will only be accepted made
out to Scot Brown.
Please pay amount due in cash, check, or money order.
International orders payable in US Funds preferred
as a Money Order from your Post Office.
International Money Order also accepted. Please follow above note.