ZoilitaGrant.net Order Form

1) Print this form and mail it to:
          Zoilita Grant, MS CCHt.
            200 Lincoln St.
            Longmont, CO 80501
2) Call (303) 776.6103
3) Fax an order to (303) 682.2384

First
Last
Address
City
	State Zip Daytime Phone ( )
Country
Method of Payment Check VISA Mastercard
Card# Exp. Date
Signature

Product Description	Item #	QTY	Price	TOTAL








			Sub-total
Shipping Charges Up to $20 ......4.00 $20.01- $50 ........5.00 $50.01-$100 .......6.00 over $100.00 ......8.00 (for every $100)			Shipping & Handling
			Tax	(Colorado Residents add 7.2% for Tax)
Please allow 2-3 week for delivery			TOTAL

Tax ID# for wholesale orders
Wholesale orders available. Please call 1.303.776.6103 for prices.