USANA
PREFERRED CUSTOMER ORDER FORM
Associate ID#: 296618
CONTACT INFORMATION ( * indicates required fields )
First Name* Last Name* Day Phone* Evening Phone* Fax Number Language Preference* English French Spanish Chinese-Catonese Chinese-Mandarin Japanese German Dutch E-mail*
Main Address (billing address):* The billing address must match the address on your credit card statement.
Street* City* State* Select State AK AL AR AZ CA CT DC DE GA HI ID IA IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VI VT WA WI WV WY Zip Code* County* USA
Shipping Address (if different from main address)
Street City State Select State AK AL AR AZ CA CT DC DE GA HI ID IA IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VI VT WA WI WV WY Zip Code County USA
Payment Method Select Credit Card VISA Master Card American Express Discover Card Number --- Card Holder's Name Expires (Month) 0 1 2 3 4 5 6 7 8 9 10 11 12 (Year) 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
SAVE an additional 10% by enrolling in AUTOSHIP. Monthly supplies will be delivered automatically. You can customize or cancel your shipments at any time. Select Yes, No, do not enroll me in AUTOSHIP to save an additional 10%.
* SHIPPING AND HANDLING Your shipping cost will be USANA's actual freight cost plus a USD $1.00 handling fee. Your shipping charge will be an estimate made at the time of your order. The estimate is a computer generated charge and is calculated using the weight of the product and the fill material.
Enter Comments, Questions or Additional Information below:
Optional ways to order: FAX this order to: 1-800-289-8081 or MAIL to: USANA DATA PROCESSING BOX 4000 TOOELE, UT 84074 or CALL Order Express: 1-888-950-9595
TO PRINT THIS FORM: Right click on your mouse and select PRINT.