irie eyes price list/order form
DESCRIPTION
price list order formTRANSCRIPT
EMail: [email protected]
Headwest Products
Price List/Order Form
Sales Rep.
2973 Harbor Blvd #118 Costa Mesa, CA 92626
Irie Eyes Eyedrops
Ph:Fax:EMail:
1-11 Cases (24+ 1/2 Oz. Bottles) $2.50CASE1-
12-48 Cases (288+ 1/2 Oz. Bottles) $54.00 $2.25CASE2-
49-359 Cases (1176+ 1/2 Oz. Bottles) $1.95CASE3-
360 Cases (8640 1/2 Oz. Bottles) $1.58CRATE-
Case PriceBottle Price Total
$60.00
$46.80
$37.92
Buyers Credit Card Info
Name on Credit Card(exactly as printed on card)
Address for Credit Card(number & Street, Suite #)
Address for Credit Card(City, State, Zip)
Credit Card Number
Card Expiration Date (mm/yy)
3 Digit Security Code (on back of card)
Company Name
Contact Name Phone Number
Fax Number or Email Address (for Receipts)
Invoice Number Invoice Amount
Signature Date