FAX Order Form

Merry Clinic MAIL/FAX Order Form

To place an order, please print this page and fax or mail your order. Click here for our policy and Guarantee. Use your BACK button to access the previous page.

Tel: 888-666-9808 (inside US) or 650-588-8335
Fax: 650-588-2544
MAIL Address: Merry Clinic LLC, 370 San Bruno Ave West, Suite F, San Bruno, CA 94066

Sold To: (If paying by credit card, note your name and address as it appears on file with your credit card company.)

Name:_________________________________
Address:______________________________
_____________________________________
City:_________________________________
State: ______ Zip: ________________
Daytime Phone: ______________________
Email: _______________________________

Ship To: Please fill in information below if the shipped to address is different

Name: _____________________________
Address:____________________________
__________________________________
City:_____________________________
State: _____ Zip: _________________
Country: _______________

ITEMS ORDERED:

Item Name	Qty	Price Each	Total Price

METHOD OF PAYMENT

o Money Order (no Cash, Personal Check)
oAmerican Express oMastercard oVisa oDiscover
Credit Card Number :____________________
Expiration Date :________________________
Signature : ____________________________

Merchandise Subtotal
State Sales Tax (California only) (See Box "A" below)
Standard Shipping & Handling (See box "B" below)
TOTAL

A: STATE SALES TAX INFORMATION:
We are required by law to collect sales tax on shipments to the state of California. Our Tax rate is 9.25%.

B: STANDARD SHIPPING

Delivery Location	Shipping Cost
US	$8.95
Canada	$20.00
Other Country	$35.00