MaxLabs
Internet Fax Form
Telephone (888) 701-DIET Fax (888) 701-1007 9189-A Winkler Drive Houston, TX. 77017
(E-Mail Address) sales@maxlabs.com (Internet Address) http://www.maxlabs.com
Last Name First Name Daytime Telephone# E-mail Address
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Shipping Address City State Zip
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| ITEM & DESCRIPTION | PRICE | QUANTITY | EXTENDED
AMOUNT |
| | $ | | $ |
| | $ | | $ |
| | $ | | $ |
| | $ | | $ |
| | $ | | $ |
| | $ | | $ |
| | $ | | $ |
| | $ | | $ |
| | $ | | $ |
| | $ | | $ |
| | $ | | $ |
| | $ | | $ |
| | SUBTOTAL | ====> | $ |
| US Postal Service- $4.95 | SHIPPING | ====> | $ |
| | | |
| | | |
| | | Total | $ |
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Circle payment type: VISA MasterCard Discover AmericanExpress
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Credit Card # Expiration Date:
| Print Name Shown on Credit Card:
| Billing Address
of credit card:
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