Print this form and then FAX to number below.

                                               Sore Nipples-Yeast Infections
 

Send your order and make payment to:                                 We accept:
B. Wilson-Clay/Kay Hoover Joint Venture                              Credit Cards (Visa/MC)
12710 Burson                                                                                Personal Checks
Manchaca, TX   78652                                                                  Purchase Orders
512-292-7227 Fax 512-292-7228                                               EIN# 74-2923741
E-mail to: bwc@lactnews.com

Name:_____________________________________________________________

 

Address:___________________________________________________________

 

Dept. (Room #):_____________________________________________________

 

City: ______________________________________State: ____Zip:____________

 

E-Mail:_____________________________________ Phone:__________________

 

Credit Card or Purchase Order Number:__________________________________

 

Credit Card Type (Visa/MC only ):________________Exp. Date:______________

 

Signature:__________________________________________________________

Number of single pads: _____ at  US $20.00 each                                 $_________
In quantities of 20 Pads: _____ at  US $16.00 each                                $_________


Sales Tax: TX or PA residents only.
Texas (8.25%) or Pennsylvania (7%)                                                          $_________


U.S. Shipping and Handling:   $6.00 for 1 to 3
                                                         $9.00 for 4 to 10
                                                       $12.00 for 11 to 20                                    $_________

 

Total                                                                                                                    $_________