Fax an order for Colonial Ear Candles!

Please print this form, fill-in the required (*) information, and fax it to:

1-877-210-1471

(Package price includes Shipping, US, Canada, Mexico)

Credit card information destroyed after processing!

* Please check one package: (Package price includes Priority Mail shipping) 

        12 candles @ 24.95___ 24 candles @ $39.95___

                 48 candles  @  $69.95 ___     100 candles @  $107.00___            

   150 candles @  $150.00___   

   More!  Enter amount @ $1 each (shipping free)_________

* Bill to:  * Name (exactly as it appears on card)____________________________

               * Address (on record with your bank)_______________________________________

                                                                                     ________________________________________

Ship to:  (If different from billing)        Name__________________________________

                                                                     Address________________________________

                                                                                    ___________________________

* Type card:  VISA ___  MasterCard ___   Discover ___American Express___

* Card number: ______________________________________________  * Exp. Date _________

Special Instructions, Comments: ______________________________________________________________________________________________________

______________________________________________________________________________________________________

Confirm my order by:  

   Fax (fax #) _____________________ Phone: _____________________ E-mail: ______________________