Gama Health
Systems, Inc.

P.O. Box 3085
McLean, VA 22103
USA

Tel: (703) 242-7697

1-800-391-6004
Fax: (703) 242-7698

 

 
   

Fax or Mail-in Order Form
      
   

Fax Orders to (703) 242- 7698

Or Mail in Order to
P.O. Box 3085
McLean, VA 22103 
USA

I understand that it is 100% Guaranteed or my money back less shipping and handling

 
 
Order Date:  __________________
      
Quantity : __________________  Quit Smoking - $89.99 each (low price!)
   
Total Amount :
  		__________________
 
 
     
Standard Shipping $9.95 per kit (Expect delivery in within 5 business days)
   		$__________
Express Delivery $24.95 per kit (within 2 business days!)
  		$__________
Canada $26.95 per kit (within 14 business days)
  		$__________
International $33.95 per kit (Outside USA & Canada)
  		$__________
      

Total:
 
    

$__________
 

Billing Information

 
 

    

 

*** We accept check by fax or phone ***

 

Policy for Payment by Check:

Please note returned check are subject to a service charge of $32 or the maximum allowed by law.  Collection costs and all penalties permitted by law will also be assessed.  We may electronically collect returned checks, service charges and other applicable charges.

 

If you would like to charge your order to MASTERCARD, VISA, AMERICAN EXPRESS or DISCOVER, you may FAX your order directly to (703) 242-7698 for fastest service!
  

 
Type of Card:
  		____________________________
Card Number:
  		____________________________
Expiration Date:
  		____________________________
Name:
  		____________________________
(As it appears on the Card)
 
Billing Address: ____________________________
  
City: ____________________________
  
State/Province: ____________________________
  
Zip/Postal Code: ______________
  
Country: ____________________________
  
Phone:
  		______________________
Email Address:
  		____________________________
Signature: ____________________________
 

  
  

  Shipping Information
 
 

     

 
Name:
  		____________________________
Company:
  		____________________________
Address:
  		____________________________
Apartment or Suite #:
  		_______________
City:
  		_____________________
State/Province:
  		____________________________
Zip/Postal Code: _______________
   
Country:
  		____________________________
Phone:
  		____________________________
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Copyright 1998-2008 Gama Health Systems, Inc.