Lice Off Retail Order Form

Lice Off™ Order Form

Name:_____________________________________________	Date:____________________

Address:____________________________________	Email:___________________________

City:__________________________________	State:_______	Zip:______________________

Home:____________________	Work:____________________	Fax:_____________________

Payment Method:

Credit Card
(Visa, Mastercard, AMEX, Discover)

Check/Money Order
(Payable to Ecopax Distributing)

___________________________ Name on Card	___________________________ Credit Card Account Number	____________ Exp. Date

___________________________________ Signature (required for credit card purchases)

Item:	Line Price:	Quantity:	Line Total:
LiceOff, 20 ml Bottle, Manufacturer's Direct-to-You Price	$9.95 US
Lice Off, 20 ml Bottle, Half Case of 6, 40% Off	$35.60 US
Lice Off, 20 ml Bottle, Case of 12, 50% Off	$60.60 US
ACU-MED Lice Comb, 25% Off	$6.00 US
ACU-MED Lice Comb, Case of 12, 45% Off	$52.80 US
Approximately $4.35 US Shipping & Handling per order. Shipping may vary by a few dollars depending on final weight. All orders sent via USPS Priority Mail, usually on the same day received. Overnight shipping is available for $10 extra..		Subtotal:
		Shipping:
		Total:

Prices and availability subject to change without notice.

MAIL TO:	FAX TOLL-FREE TO:	TOLL FREE:
Ecopax Distributing, Inc. 204 Washington Street Oregon City, OR 97045	877-238-9939	1-877-LICEOFF (542-3633)