Seacure Protein US Territories/Associations Fax Order Form

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 (808)356-0166. 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.

Pricing for SEACURE® is as follows:

1 bottle for US $29.95 with FREE shipping via US Priority Mail,
2 bottles for US $57.90 ($28.95 each) with FREE shipping via US Priority Mail,
3 bottles for US $83.85 ($27.95 each) with FREE shipping via US Priority Mail,
4 bottles for US $107.80 ($26.95 each) with FREE shipping via US Priority Mail,
5 bottles for US $129.75 ($25.95 each) with FREE shipping via US Priority Mail.

Pricing for SEAVIVE® and INTESTIVE® is as follows:

1 bottle or box for US $26.95 with FREE shipping via US Priority Mail,
2 bottles or boxes for US $51.90 (US $25.95 each) with FREE shipping via US Priority Mail,
3 bottles or boxes for US $74.85 (US $24.95 each) with FREE shipping via US Priority Mail,
4 bottles or boxes for US $95.80 (US $23.95 each) with FREE shipping via US Priority Mail or
5 bottles or boxes for US $114.75 (US $22.95 each) with FREE shipping via US Priority Mail.

We will mix orders and give you the volume discount. For example, order 2 bottles SEACURE® of and 1 box of INTESTIVE® and receive all 3 for the price of US $80.85 (2 bottles of SEACURE® at US $27.95 each and 1 box of INTESTIVE® at US $24.95) with FREE shipping via US Priority Mail!

If you are ordering 1 bottle of SEACURE® or SEAVIVE® or 1 box of INTESTIVE®, you can upgrade your shipping to US EXPRESS MAIL for $10.00. US Express Mail will deliver on the weekends.

If you are ordering 2 or more bottles of SEACURE® or SEAVIVE® or 2 or more boxes of INTESTIVE®, you can upgrade your shipping to US EXPRESS MAIL for $12.00. US Express Mail will deliver on the weekends.

Please check the following box:
I want to upgrade to US Express Mail shipping for my order!

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 OR from your checking account.

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):

________________________________________________________________________

CHECKING ACCOUNT PAYMENTS

You can pay for your order with funds from your checking account. Just enter the information "EXACTLY" as it appears on your check into the boxes below. We will "cut a check" using the information you provide and send you a copy of it with your order.

Saves time! Saves money (no stamp)! No need to write and mail us your check. Just as fast as using a credit card! Your order is shipped right away.

If you have trouble locating the information that is needed for the form below, please take a look at the sample check below this form for some additional help.

PLEASE NOTE: All checks returned due to Non-Sufficient Funds (NSF) will be charged a $25.00 NSF Fee! Also, please void the check that you use so that you do not use the same check number twice!

Your name

Your address

City

Country

Zip code
Check #

ABA #

The ABA # is located
close to your check #
and looks like this
01-5678/1234

Pay To The Order Of NATURE DOC

Your Bank's Name

Your Bank's Address (May omit if not on check.)

Your Bank's City

Your Bank's Country

Your Bank's Zip Code

Enter the numbers from the bottom of your check in the 2 boxes below:

Routing # Account #

The sample check below provides some additional help for locating the information needed in the above form.

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 (808)356-0166.

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