MAIL TO: D-Mannose.com
125 Tremont St.
Rehoboth, MA 02769 USA
Phone (508) 252-5294
FAX THIS FORM TOLL FREE TO 1-800-778-2357
Billing Address
Please fill out completely and PRINT clearly.
Name
Address
City
State/Province
Zip Code
Country
Email (optional)
Phone Numbers
(home)
(work)
Shipping Address Please fill out shipping address if different from above.
Name
Address
City
State/Province
Zip Code
Country
Email (optional)
Phone Numbers
(home)
(work)
Credit Card Information Please fill out completely or your order can not be
processed
Name
(As it appears on
the credit card)
Credit Card #
CVV # (the last 3 numbers on the signature strip located on the BACK of
your credit card, for added security);
Expiration Date
Signature
Method of Payment Visa MasterCard Discover Check**
**Please make checks payable to Global Sweet Polyols, LLC
Please
visit www.D-Mannose .com products
page for the following information
SKU #
Description
Qty.
Price
If you have any questions please contact D-Mannose
U.S.A.
either by calling (508) 252-5294 or
Visa