DermabrasionCrystals.com

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ORDER FORM

PLEASE PRINT AND FAX TO US

Fax order to 631-582-2820  or  Call   516-592-3488

Shipping address:                  ____________________________________    Residence  or  Business

                                             ______________________________________

                                             ______________________________________

Phone Number    _____________________________________  

Credit Card #      _______________________________________   Type:  V    MC   Discover    Amex

 Cardholder Name:               _______________________________________     Expires________________ Security code*______________

Billing address                    _______________________________________

                                          _______________________________________    

Cardholders Signature      _______________________________________

 Email Address_________________________________     We will send your tracking number

SIZES----90, 100, 120, 180                                                         11-07-08

Please ship the following:  Size     Item #     Nbr  each              X          Price each      =        Total Cost

1.                                   _____    ______      _________                       _________               $_________

2.                                   _____    ______      _________                       _________               $_________

3.                                   _____    ______      _________                       _________               $_________

TOTAL                                                                                                                      $  __________

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