Amber Waves Fiber Supplement - Order Form to Print Out

TO MAIL YOUR ORDER: Please print out a copy of this page, complete the order form and mail it to:
AMBER WAVES 432 Blue Knob Road, Portage, Pennsylvania 15946, USA.
Please make your checks or moneyorders payable to Amber Waves.

To Fax Your Order In: Please print this page and fax it to us at: 814-239-2474

Name: __________________________________________________

Address:_________________________________________________

________________________________________________________

State/Providence: _______________ Zip/Postal Code:_____________

Country:_________________________________________________

E-Mail Address: ___________________________________________

Telephone Number: ________________________________________

Fax Number: _____________________________________________

Fiber Formula: Price = $14.95 x _________(Qty) = $___________

Shipping and Handling: $4.00 First Item, $3.00 Each Additional Item Shipping:$___________

TOTAL:___________