Mail and Fax Order Form

Mailing Address
Roots Herbal Industries and Exports
Attn: Mail Orders
927 Holly Blossom Court
Great Falls, Virginia, 22066 , USA

Fax: 831-301-8139


First Name:_______________________________________
Last Name(family or surname):_______________________________________
Shipping Address:_______________________________________
 _______________________________________
 _______________________________________
Phone number:_______________________________________
Email (if available):_______________________________________

Product Quantity Price (US $)
_____________________________________ _______ __________
_____________________________________ _______ __________
_____________________________________ _______ __________
_____________________________________ _______ __________
  Subtotal __________
  Shipping __________
  Total __________

Payment method: Check_____   MO_____  Cash_____  Credit Card_____

For Credit Card Orders:
Credit Card Number:____________________________________
Expiration Date: ____________________________________
Account Holder's Name:____________________________________
Exact Credit Card Billing Address:____________________________________
 ____________________________________
 ____________________________________


www.rootsherbal.com