Amber Technology Fax Order Form - Attention: Rick
Print a copy of this form, fill it out and fax to Amber Technology 801-428-0125 (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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