By Fax: (604) 325-0020, By Mail: 3315 - 349 West Georgia Street., Vancouver, B.C., CANADA V6B 3Y3
Member Number: _________________ Ship to:(if different)
Name:___________________________ Name:________________________________
Street:_________________________ Street:______________________________
City:___________________________ City:________________________________
Prov./State:____________________ Prov./State__________________________
Postal/Zip Code:________________ Postal/Zip Code:_____________________
Telephone:______________________ Telephone:___________________________
E-Mail Address:_________________ E-Mail Address:______________________
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Item# Product Description Price per Units Total Price
Unit Ordered
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|Credit Card: MC or VISA (circle one)| Sub Total (1) ______________
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|Card #:_______________________________| Shipping and Handling (2) ______________
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|Expiry Date:______/______ | Sub Total (3) ______________
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|SIGNATURE:____________________________| 7% GST (Canada only) (4) ______________
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|Ship by: Mail or Courier (circle one)|
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|Money Orders payable to Club Vitamin | TOTAL (5) ______________
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