Fax/Mail Order Form
We accept Visa / Mastercard, Check or Money Order
(except US Postal Money Orders)
 
Item   Price US$: Qty: Subtotal: 
Brazil Live Coral - 120 Capsules     
1 to 5 bottles   24.95 X = $
6 to 11 bottles   22.95 X = $
12 or more bottles   19.95 X = $
  1 Subtotal   $
2 Shipping
3 Total Payable Add lines 1 & 2  $
Billing Address
Your Credit Card can only be processed if correct address and phone number that your credit card is registered to is supplied.  
Name:
Address:
City:
State/Province:
Zip/Postal Code:
Country:
Phone #:
Email:
 (for order confirmation)
Credit Card Information
Credit Card:          Visa MasterCard
Card #:
Card Expiry:                     Month:  Year: CVV2# :
Name:
 (as shown on card)
Shipping Address (Only if different then your Billing Address)
Address:
City:
State/Province:
Zip/Postal Code:
Country:
Phone #:
 
Mail Order Form with payment to
AlgaeCal Inc, 401-1250 Homer St, Vancouver, BC, Canada V6B 1C6
or by Fax to 604-899-4572