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Credit Card Purchases
American Longevity Faxable Order Form
Michel Leszyk~AssociateID# 14289601
Orders:1-800-982-3197 * FAX: 1-619-934-3205
Customer Service: 1-800-982-3189
Print and complete the following and fax to (619) 934-3205 or Mail to:
The Long Life Source
C/O Michael Leszyk
532 Linden Street
Bethlehem, PA 18018
Name____________________________________________
Address__________________________________________
________________________(We cannot ship to P.O. Box)
City______________________________State_____________
Zip___________
Phone (___)_____________________________
Email _________________________________
PRODUCT** CODE ** QTY ** PRICE ** TOTAL PRICE
_________ _______ _______ _______ ____________
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_________ _______ _______ _______ ____________
_________ _______ _______ _______ ____________
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SUB TOTAL____________
Shipping and Handling( Add 7% )____________
Associate Kit (first time customers only)_____ 6.00 U.S.Dollars
(To recieve Wholesale Prices on all Future Purchases) This is a One Time Fee!
If already a Member:ID#_____________________
TOTAL REMMITANCE _____________ U.S. FUNDS
Credit Card Type:VISA_____ MC_____ DISCOVER_____ AMEX______
Number____________________________________
Exp. Date__________________
Print Name___________________________(as it appears on card)
Signature__________________________________
Get Your FREE 90 Minute Audio Tape "Dead Doctors Don't Lie" When You Contact me at: mike@Longevity.zzn.com
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