CANADIAN RETAIL
PRODUCT ORDER FORM
Please complete the entire form below to generate an accurate and printable purchase order to fax to us. Note: None of the information entered in this form is saved or recorded by StemTech.

Item Code
Description
Price
Quantity
Total
1001
StemEnhance Single
$69.75
1001a*
StemEnhance Single ASP
$57.95
 
Shipping & Handling Charges
 
Resident of Canada (8% of order, $14.95 minimum)
Calculated on next page.
 
  Please enter your local  Sales Tax Rate
%
 
Invoice TOTAL and S&H charge will be calculated after submitting this form  
*YES, please sign me up for StemTech's AutoShip program. I understand that StemTech will send me the products I select each month and I authorize StemTech to charge my credit card for each monthly order. I undestand that I may cancel my AutoShip at any time.

Ship To:  
Full Name
Address
"Canadians MUST use a street address to ensure timely delivery and no added charges"
City
State Zip
Phone
 
Email  Address
Independent Distributor Referred By
ID Number 
Payment Method: (Please check one)
Please check one: VISA MasterCard AMEX Discover
Cardholder Name:
(as appears on card)
Credit Card Number:
Expiration Date: Ex: 09/2007
Total Charges: Calculated on final printable page
***Signature Required on final purchase order.

You, the buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.

For Faster Service:
Online Orders > Click to view online order form
Fax Orders > (541) 885-9993
Phone Orders > 888-StemTech (credit card only)
Mail Orders:
StemTech HealthSciences, Inc.
P.O. Box 489 Klamath Falls, OR 97601
30-Day 100% Money Back Guarantee