Please Print
To order call Customer Service at 800-455-9197
(7am to 4pm PST) or fax form to 626-303-0026
Name:                                                                                 Date:                                                        
E-mail:                                                                                                                                                
Phone:                                                                                Fax:                                                          
Mailing Address:                                                                                                                                  
City, State, Zip:                                                                                                                                    
Shipping Address:                                                                                                                                
City, State, Zip:                                                                                                                                    
How did you hear about us?                                                                                                                
Suggested
Retail
Product Name
Qty.
Unit Price
Total
68.95
Pura All Natural Collagen
Hydrating Day Cream - SPF 25
 
48.00
 
68.95
Pura All Natural Collagen
Night Renewal Cream
 
52.00
 
79.95
Pura All Natural Collagen
Serum
 
58.00
 
83.95
Pura All Natural Collagen
Serum With Vitamin E
 
62.00
 
137.90
Pura All Natural Collagen
Day and Night Kit
Shipping & Handling is FREE
 
90.00
 
217.85
Pura All Natural Collagen
Spa Kit Shipping & Handling is FREE
 
145.00
 
 
Subtotal 1:
 
 1Discount:
Discount 1:
 
 2Tax: CA residents add 8.25%
Subtotal 2:
 
 3Shipping & Handling: $7.00. Special Offer:
Tax 2:
 
 
Subtotal 3:
 
NOTES: Orders paid using checking information will be shipped upon clearance of the payment. Returned checks or insufficient fund checks shall be subject to 3 times the bank fee.  
Shipping & Handling 3:
 
 
Total:
 
Payment Type: Check      MasterCard      Visa      American Express     Discover      
If paying by check fill in lines 1 through 5. If paying by credit card fill in lines 1, 2, & 6.
1. Owner's Name as Shown on Check/Card:
2. Check/Card Billing Address:
(City)                                                                        (State)                           (Zip)                       
3. Bank Name:                                             Branch Name, #, or City:                                            
4. Bank Routing Number: |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
5. Account #: |     |     |     |     |     |     |     |     |     |     |     |     |      |   Check #: |     |     |     |     |     |     |
6. Card #: |     |     |     |     |     |     |     |     |     |     |     |     |     |     |     |    Exp. Date:       /        /        
I authorize PURA Collagen, Inc. to use my credit card/checking account to purchase the product(s) marked above. I authorize PURA Collage, Inc. to amend and charge my card/account for clerical or mathematical errors used to calculate the total due.
Applicant Signature:__________________________________________Date:_______________
Office
Use:
 Date:     /         / Processed By:
Order #:   |    |    |    |    |    |    |    |    |    |