PERFECT WOMAN WHOLESALE Order Form
 *Print this page, fill out all information, and send this form by mail or fax to:
Perfect Woman Wholesale
165 Castilian Dr
Goleta, CA 93117
FAX: 805-681-8201 		** For orders outside US, please contact us first.

1.

Customer Information

Name:

 ________________________________________________________

Company:

 ________________________________________________________

Address:

 ________________________________________________________
Address2: ________________________________________________________

City:

 ________________________________________________________

State:

_________________________ Zip: ______________________

Country:

 _________________________

Phone:

 _________________________          

Email:

 ________________________________________________________

2.

Shipping Information (if different from above )

Name:

 ________________________________________________________

Company:

 ________________________________________________________

Address:

 ________________________________________________________
Address2: ________________________________________________________

City:

 ________________________________________________________

State:

_________________________ Zip: ____________________

Country:

 _________________________

Phone:

 _________________________          

3.

Payment Method: upon the reciept of the payment, the order will be processed.

Select one

Money Order / Cashiers Check (Payable to Cosmeceutical Technologies in US$ only)

Visa / MasterCard / American Express (circle one)
 

Credit Card Number:
 

Expiration Date:

/  Signature: _________________________
   

4.

Shipping Method :

Select one

UPS Ground

Client UPS Account #    _________________________

UPS 3 Day

 Client FedEx Account # _________________________
UPS 2nd Day Shipping Instructions:
FedEx

Call for Shipping

5.

Wholesale Unit Price: Minimum Order: 50 Units

 
50-100
101-250
251-500
501 and over
Breast Enlagrement Cream - 4 oz. jar
$22.00
$20.00
$18.50
Breast Toning & Firming Complex - 2oz. bottle
$18.00
$17.00
$16.00

 
Quantity

Unit Price

 Total  
Breast Enlargemet Cream

$

  $
 
Breast Toning & Firming Complex

$

 $

Subtotal:

$.
 

Shipping:

$.

Grand Total:

$.