Mail and Fax Order Form

Mailing Address
rootsherbal
14781 Memorial Drive #2876
Houston TX, 77079
USA

Fax (USA): 703-229-1716


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

Product Quantity Price (US $)
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  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:____________________________________
 ____________________________________
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www.rootsherbal.com