Faxorderform

Sold To: (If paying by credit card, note your name and
address as it appears on file with your credit card
company.)
Name: ____________________________________
Address:___________________________________
__________________________________________
City:______________________________________
State: ________________ Zip: _______________

Ship To: Please fill in information below if it is different
from “Sold To” address:

Name: ____________________________________
Address:___________________________________
__________________________________________
City:______________________________________
State: ________________ Zip: _______________

Item Name	Quantity	Unit Price	Total Price
Porever Pure Night Immediate Blemish Control for Normal Skin		$36.80
Porever Pure Night Immediate Blemish Control for Dry Skin		$36.80
Porever Pure Night Immediate Blemish Control for Normal Skin		$36.80

METHOD OF PAYMENT:
Please make sure that your billing name and address above are the same as
those on file with your credit card company.
oAmerican Express    oMastercard   oVisa   oDiscover   oDiners Club   oMoney Order

Credit Card Number:
Expiration Date:
Signature:
Daytime Phone (          )               -
Nighttime Phone(          )               -
Email:

Shipping Cost
Within the United States:
$6.00 for the first item, $2.00 for each additional item. Shipping is free for orders of $80 or more.

Outside the United States:
$13 for the first item, $2.00 for each additional item. Shipping is free for orders of $120 or more.

Subtotal
Shipping & Handling (See box below)
Other
TOTAL


NexCosm FAX Order Form To place your order, please print and complete this form and fax or mail it to us. To return to the previous page, please click BACK on your web browser. Click here for our shipping and return policies. Toll Free: 866-391-8568 (inside US and Canada ) Fax: 703-264-3967 MAIL: NexCosm LLC, PO Box 711422, Herndon, VA20171-1422 Items Ordered: © NexCosm LLC.