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Printable Order Form
We understand that some of our customers may feel uneasy about ordering via the Internet. We still want to give those customers an opportunity to try our product. Simply print out this order form (Go to "File" and "Print". THIS FORM WILL PRINT ON TWO PAGES) and mail it along with a check or money order payable to "EZ Discount Store " to:

EZ Discount Store
PO Box 241471
Milwaukee, WI 53224


Please print clearly.
See our web site for best prices.
Customer Name:
Address:
City: State: Zip:
Phone: Fax: E-mail:
Qty Description Price Total
 
 
  Breast Gain Plus - 1 Bottle
$49.95
  
  Breast Gain Plus - 2 Bottles
$89.95
  
  Breast Gain Plus - 4 Bottles
$149.95
  
  Breast Gain Plus - 6 Bottles
$199.95
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SUBTOTAL:  
SALES TAX:
(5.5% in WI)		  
SHIPPING (USA ONLY): $7.00
SHIPPING (NON-USA ONLY): $25.00
TOTAL AMOUNT: $

 

PAYMENT INFORMATION
PAYMENT TYPE:* (Please select one.) No Cash or C.O.D. accepted. Check/money order payments accepted with postal mail orders ONLY.
  Credit Card   Check**   Money Order
** Make checks payable to: EZ Discount Store (checks must be in US dollars ONLY)

CREDIT CARD PAYMENT INFORMATION:
TYPE OF CARD:*
  Visa   MasterCard   American Express
CARD NUMBER:* (Must be 16 digits)
EXP. DATE*
 CCV CODE
    |    |    |    |    |    |    |    |    |    |    |    |    |    |    |    |
CARDHOLDER'S NAME AS IT APPEARS ON THE CARD:*
 
CARDHOLDER'S SIGNATURE:* (Orders can not be processed without signature)
X

Mail your order / check payable  to:
EZ Discount Store
PO Box 241471
Milwaukee, WI 53224