ORDER BY FAX

To order the End the Habit Stop Smoking Program by fax, simply print out this page, fill it in, and fax it (toll-free) to 1-888-577-QUIT (7848) Or, if you prefer, just write the information on a piece of paper and fax that.

Please make sure you fill in ALL the information required! Please use BLOCK CAPITALS.

Your Name (As it appears on your credit card):  
Your Email Address (use block capitals)  
Your Telephone number:  
Your Credit-Card Billing Address:

  

Zip/Postal Code:  
Country:  
Shipping Address (if different):

 

Zip/Postal Code:  
Country:  
Credit Card type: (please circle)

Visa        Mastercard
Credit Card Number:
                               

Expiry Date:    MM/YY

   Security Code from back of card: (look for the last 3 digits)  
Quantity Description Price
USD$		 Total
  End the Habit Deluxe Stop Smoking Program 167.00  
  End the Habit Standard Stop Smoking Program 147.00  
  Shipping & handling :  Canada & US - 14.95  
  Shipping : Outside Canada & US - 29.95  
 

Sub Total

    
 

Canadian residents, please add 5% GST

   
 

TOTAL

    

I authorize Virtual Web Marketing Inc, to charge to my credit card the total amount shown above.

________ __________________
date signature

Your order will be processed and shipped out the next business day.

Virtual Web Marketing Inc, 50 Southshore Dr, Brooks, AB, T1R 1M4, Canada.
GST # 83858 9455 RT 0001
Email Us
 Please complete and fax to 1-888-577-QUIT (7848)