Lice Off Retail Order Form

Lice Off™ All-Natural Non-Toxic Head Lice Treatment Order Form

Name:________________________________________	Date:__________________

Address:_______________________________	Email:_________________________

City:______________________________	State:_______	Zip:__________________

Home:_________________	Work:__________________	Fax:___________________

Payment Method:

Credit Card
(Visa, Mastercard, AMEX, Discover)

Check/Money Order
(Payable to Ecopax Distributing)

___________________________ Name on Card	___________________________ Credit Card Account Number	____________ Exp. Date

___________________________________ Signature (required for credit card purchases)

Item:	Line Price:	Quantity:	Line Total:
LiceOff, 15 ml Bottle	$9.95 US
Head Lice Emergency Kit	$24.95 US
Lice Off, 15 ml Bottle, Half Case of 6, 40% Off	$34.95 US
Lice Off, 15 ml Bottle, Case of 12, 50% Off	$58.95 US
ACU-MED Lice Comb, Half Case of 6, 40% Off	$27.95 US
ACU-MED Lice Comb, Case of 12, 50% Off	$46.95 US
Shipping & Handling: 1-6 Individual Items...........$5.00 7-12 Individual Items...........$6.00 13-23 Individual Items...........$7.00 24-35 Individual Items...........$8.00 36+ Individual Items...........No Charge		Subtotal:
		Shipping:
		Total:

Prices and availability subject to change without notice.

MAIL TO:	FAX TOLL-FREE TO:	TOLL FREE:
Rainforest Essentials PO Box 22761 Portland, OR 97269-2761	877-238-9939	1-877-LICEOFF (542-3633)