Vernon Furlow Company, Inc.-FAX FORM

Vernon Furlow Company, Inc.

Melrose Hand and Skin Cream Order Form
www.melrosecream.com

Please print
First Name ___________________________Last Name__________________________________

Shipping Address______________________________________________________________________

City ___________________________________________________ State____________ Zip __________

Daytime Phone: (_____)______________________ Evening Phone: (_____)________________________

Email Address: _______________________________________________________________________

Date Ordered: _________________

Method of Payment:

_____ Call- in Credit Card Order: 1-866. 372. 4691 - toll free
_____ Fax Credit Card Order: 281. 476. 9933
_____ Check/ Money Order (No cash or C.O.D.)
Please make check payable and send to:
Vernon Furlow Company, Inc. / P.O. Box 1174 / Deer Park, TX 77536

___VISA ____MASTERCARD ____AMERICAN EXPRESS ____DISCOVER

Name on Credit Card ______________________________ Signature_____________________________

Credit Card # ____________________________________ Card Expiration Date_____________________

Item Total	Description	Cost per Jar	Sub Total Price
	Four oz jars of Melrose Hand and Skin Cream	$8.00
Sales Tax (Texas Residents: add 8.25%)
Shipping/ Handling Fee:
Total

Shipping & Handling Fees

Order Subtotal	Standard Shipping
Up to $32.00	$6.00
$32.01 to $48.00	$8.00
$48.01 to $96.00	$10.00
96.01 to $150.00	$12.00
$150.01 Plus	$16.00

Thank you for your order. Allow 5–7 working days to receive your order.
Please print and include completed order form with your check

P.O. Box 1174 Deer Park, TX 77536 Toll Free: 866. 372. 4691 Fax: 281. 476. 9933