FitRx.com Mail/Fax Form

		Please fax this order form to: (888) 229-0697 or send it to: FitRx.com, Inc. 1629 S. Roselle Rd. Roselle, IL 60172		Fax-Mail Order Form Make your money order or cashiers check payable to: FitRx.com, Inc. (NO PERSONAL CHECKS)
Product #	Description		Unit Price		Quantity	Total




Sub-total
Sales Tax (IL add 2.00%)
Shipping						6.95
P.O. Box & APO/FPO orders please call (877)GO-FITRX (463-4879) for shipping costs.
Total

Cashier's checks and money orders received without the correct amount or without shipping charges included will be returned.

Method of payment: Money Order, Cashier's Check (sorry, no personal checks), Visa, MasterCard, Discover and Amex

Ship To: Name: ______________________________________ Address: _____________________________________ Address: _____________________________________ City: _________________________________________ State: ____________________ Zip: _______________ Phone number: ________________________________ Email address:_________________________________	Charge My: (If paying by credit card) _____ Visa _____ Mastercard _____ Discover _____ AMEX Card Number: ____________________________________ Expiration Date (MM/YYYY): __________________________ Name on card: _____________________________________ Signature: ________________________________________
Credit Card Billing Address (if different): Name: _______________________________________ Address: _____________________________________ Address: _____________________________________ City: ________________ State: ____ Zip: ___________	Send a catalog to a friend: Name: ___________________________________________ Address: _________________________________________ Address: _________________________________________ City: ____________________ State: ______ Zip: _________