Mail Order Form Evolution-X

Ship To Information:

Name:

Address 1:
Address 2:

City:
Province:
Postal Code:
Country:

Telephone:

Email address:

Is this your first time taking a B5 vitamin therapy?

No .........................................Yes

Order Information.

I would like to order:

(price includes $8.24 CAD shipping)

1 bottle of
B5 Supplements..............$55.63 CAD

2 bottles of
B5 Supplements.............$103.00 CAD

3 bottles of
B5 Supplements.............$150.41 CAD

1 bottle of B5 Supplements
and 1 Skin Advancement System
.....................................$88.78 CAD

other
(please write below)

(please write in and calculate total if ordering more than 3 bottles, or if you would like to order a different product. Shipping is a flat $8.24CAD regardless of order size. For other products listed in US Dollars, please use the online
currency converter at: http://www.xe.com/ucc/

We will send you an email confirmation as soon as your order ships.

Please print this page and mail with check or money order to: Evolution-X 11470 Sunrise Gold Circle #4 Rancho Cordova, CA 95742 United States	Checks should be written out to Evolution-X. Delivery generally takes 5-9 days from the time we receive your order form.