Amber Technology Fax Order Form - Attention: Rick

Print a copy of this form, fill it out and fax to Amber Technology 801-286-2280 ( If for some reason you can not get it to go through then please call 1-877-727-8243 for your order - please give name of our website )

Please print all entries except signature

Name: __________________________

Street Address: ______________________________

City: ____________________________

State: _______________  Zip Code: __________

Phone Number day: ________________ evening: ________________

E-Mail Address: ____________________________________________

Product you want to order and size?



If Parvaid....
I need PARVAID to help my (dog, fox, raccoon, ferret, other) recover from: ___________.

Animals Weight: _________, Sex: ________, Age: _________, Breed:______________.

General health prior to present condition: _____________________________________.

                       Quantity                 Product              Shipping Method

Please send ______________ of _______________ via ________________.

  Also send ______________ of _______________ via ________________.


Add additional shipping costs for over-night delivery Yes___ No___

Payment method: ________________ C.O.D. or Credit Card (Visa, MC, Disc)

Card Number: ______________________ exp date: __________

Name of Card Holder: ______________________________

Signature: ______________________________

Thank You for your interest in Amber Technology.



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