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FAX Order Form
for US Territories/Associations

Print out this form using your browser, then fill in the information needed to place your order. Fax the completed form to us at 817-977-1240. We will process it right away and send your order to you within 24 hours (excluding weekends).

ORDERING INFORMATION:

Quantity
bottles of SEACURE®, 180 capsules per bottle, 500 mg each.
bottles of SEAVIVE®, 90 capsules per bottle, 500 mg each.
boxes of INTESTIVE®, 120 capsules per box, 500 mg each.
containers of SEACURE® for pets, 100 grams with scoop.
containers of SEACURE® for pets, 500 grams without scoop.
containers of SEACURE® for pets Chewables, 120 chewable tablets.

Pricing for SEACURE® is US $29.95 per bottle.

Pricing for SEAVIVE® and INTESTIVE® is US $27.95 each.

Pricing for SEACURE® for pets, 100 gram containers and SEACURE® for pets Chewables, 120 chewable tablet containers is $29.95 each.

Pricing for SEACURE® for pets, 500 gram containers is $119.95 each.

CUSTOMER INFORMATION:

NOTE: All fields marked with an * are REQUIRED!

First Name:* ______________________________________________________________

Last Name:* ______________________________________________________________

e-mail address* ____________________________________________________________

Address Line1* ____________________________________________________________

Address Line2 _____________________________________________________________

City* ____________________________________________________________________

Country* _________________________________________________________________

Zip Code* ________________________________________________________________

Contact Phone Number (if available) ____________________________________________

PAYMENT INFORMATION:

You can pay for your order with your credit card (VISA, MasterCard, American Express or Discover).

CREDIT CARD PAYMENTS

Credit Card Type: (fill in one circle)
Visa MasterCard American Express Discover

Credit Card Number: ______________________________________________________

Expiration Date (Month/Year): ______________________________________________

Name of the person as it appears on the credit card (REQUIRED):

________________________________________________________________________

Comments/Suggestions:


USE THE PRINT OPTION ON YOUR BROWSER TO PRINT A COPY OF THIS FORM. FILL IT IN AND FAX THE COMPLETED FORM TO US AT 817-977-1240.

Return to SEACURE-PROTEIN order page for US Territories/Associations.

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SEACURE® is a registered trademark of Proper Nutrition, Inc.

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