BILLING INFORMATION
NAME ________________________________
ADDRESS _____________________________
CITY _____________________ STATE ______
ZIP CODE _________________
PHONE ___________________
EMAIL __________________________
SHIPPING INFO (SAME AS BILLING INFO)
NAME ________________________________
ADDRESS _____________________________
CITY _____________________ STATE ______
ZIP CODE _________________
PHONE ___________________
EMAIL __________________________
  
CHECK OR MONEY ORDER
Orders paid by personal check will be shipped after check clears.		  
CARD NUMBER ________________________________ EXP _________
SIGNATURE _____________________________________
Item / Description
Quantity
Unit Price
Total
Tonic Gold - Original (10ml/.34oz)  
$60.00
 $
Tonic Gold - Professional (10ml/.34oz)  
$100.00
 $
Total Products
$
FOR SHIPPING WITHIN THE USA
PURCHASE
PRIORITY (2-3 Days)
EXPRESS (1-2 Days):
Up to $240
$5.00
$15.00
$241-$900
$7.00
$19.00
$901-$1500
$12.00
$26.00

Orders are shipped within 1-2 days of receipt. If insurance, international shipping, or special handling are needed, please call.

SHIPPING
 $
SUBTOTAL
 $

Colorado Residents add Sales Tax (Multiply SUBTOTAL by 4.75%)
Arizona Residents add Sales Tax (Multiply SUBTOTAL by 9.35%)
California Residents add Sales Tax (Multiply SUBTOTAL by 7.25%)
SALES TAX
 $
PROMO CODE _______
GRAND TOTAL
$

FAX TO: 303-530-7716
PHONE: 1-888-8TONICS
PHONE:  (1-888-886-6427)
(303)530-9467

MAIL TO:
Suryanivas Health Products
PO BOX 18958
Boulder, CO 80308