Herbalife Fax Order Form

Please note this is a provisional order form. Please fill in the form and fax back to us at 09 271 4482.

Billing Address Details
First Name:  
Last Name:  
Address:  
 
City:  
Postal Code:  
Email:  
Phone:  



Shipping Address Details
Address:  
 
City:  
Postal Code:  



Quantity Product
Size
Colour
 Price
         
         
         
         
         
         
         
         
         
         
   
Freight
 $ 8.95
 
Total
 $



Payment Details
Card Type: Visa  /   Mastercard (please circle)
Credit Card Number:  
Expiry Date:  
Signature:  

Please note that there is a $8.95 freight charge on every order.