Secure International Order Form
Note:
After you have selected the products you want to purchase simply fill out this form and click the "Submit Order" button at the bottom of this page.
"Thank you!"
Order Information
Offer/Distributor #:
(optional)
Invoice #:
[office use only]
--------------------
Quantity:
----
Product & Price:
Items:
*
--------------------
Sub-Total:
Shipping:
[International and Distributor Orders leave blank]
NOTE:
Your credit card
WILL NOT
be charged until a VitaPurity
Representative contacts you and you approve the shipping cost.
Grand Total:
[International and Distributor Orders leave blank]
Credit Card Information
Accepted Cards:
Card Number:
*
Expiration Date:
(month/year)
*
CVV Number:
(3 or 4 digits)
*
click for more information
(*) Required entry - If credit card information is left blank order will be deleted and not processed.
Customer Billing Information
First Name:
*
Last Name:
*
Company:
Address 1:
*
Address 2:
City:
*
State/Province:
*
Zip/Postal Code:
Country:
*
Phone:
*
E-Mail:
*
Comments:
Customer Shipping Information
(if different from above)
First Name:
Last Name:
Company:
Address 1:
Address 2:
City:
State/Province:
Country:
Zip/Postal Code:
Phone:
(*) Required entry - If left blank order will not be processed
A VitaPurity Representative will contact you shortly to confirm your order.
"Thank you for choosing VitaPurity!"