DOCTOR'S SENIOR EXERCISETM
MAIL/FAX ORDER FORM
Simply print out this form, fill it out, and either FAX or mail it to the locations listed below...
SOLD TO (First, Middle Initial, Last Name): SHIP TO (if different than sold to):
Street: Street:
City, State, ZIP: City, State, ZIP:
Phone: FAX: Phone: FAX:
E-MAIL: E-MAIL:
Payment Method:  checkbox.jpg (1027 bytes) Check  checkbox.jpg (1027 bytes) Visa checkbox.jpg (1027 bytes) MasterCard  checkbox.jpg (1027 bytes) American Express  checkbox.jpg (1027 bytes) Discover
Name (as it appears on credit card):

Card Number
      cardno.jpg (5989 bytes)
Card Holder Signature:

Expiration Date:
                           expdate.jpg (1415 bytes) /  expdate.jpg (1415 bytes)
QTY DESCRIPTION EACH TOTAL
       
       
       
       
       
       
       
       
Mail: Please make your check or money order payable to:

Doctor's Exercise
P.O. Box 480009
Fort Lauderdale, FL 33348

FAX your credit card orders to:     1-954-564-8158
Phone orders call:                             1-954-564-8158

 SUBTOTAL  
SALES TAX*  
S&H  
TOTAL ENCLOSED  

*  Florida residents please add 6% sales tax