FAX ORDER FORM

To order AGESTOP products by fax with a credit card: 1. Fill out the following form with your keyboard; 2. Print out completed form from your browser; 3. Fax to: 087 0131 1956

CUSTOMER INFORMATION:

Title:	Mr. Ms. Mrs. Dr.
First Name:
Surname:
Address:
Postcode: (please use all upper-case letters)
City / Town / County:
Country:
Email:

ORDER INFORMATION:

Product	Qty.	Price	Subtotal
		£	£
		£	£
		£	£
		£	£
		£	£
		£	£
		£	£

Postage, packing and processing for all fax orders	+ £2.95
ORDER TOTAL:	£

INVOICE INFORMATION:

Select one:   Visa       MasterCard      American  Express
Credit Card Number:
Expiration Date:
Card Holder's Signature: _______________________________