Fax/Mail Order Form

Special Discount for Fax/Mail Orders ONLY

Free Shipping

1 Bottle GHR 15 @ $34.99  or 3 Bottles GHR 15  @ $69.98

     Customer Information:
            Name: ___________________________________________________

            Address:__________________________________________________

     City, State:____________________________________________________
              Zip:

            Phone:____________________________________________________

    Shipping Information:
    [  ] Check here if the same as customer Information

            Name: ___________________________________________________

            Address:__________________________________________________

     City, State:____________________________________________________
              Zip:
            Phone:____________________________________________________

  Email Address____:_______________________________________________
    Order Information:

Product	Quanitity	Price	Shipping	Total
1.	|	|	|	|
2.	|	|	|	|
3.	|	|	|	|
			Total

Payment Information:     [  ] Money Order   [  ]  Visa  [  ]  Mastercard      [  ]  American Express   [  ]  Discover     Card Number_________________________________________________     Expiration Date ______________________________     Signature____________________________________

Mail or Fax to:     TRS     P.O. Box 131543     Houston, TX 77219     FAX : 1-877-380-8188