Products for Seniors
Use this form to pay by mail with a check, money order or credit card.
Print this page then fill in your personal information and items purchased.
ORDERED BY: ALTERNATE SHIPPING ADDRESS
(if different than name and address at left)
Name:
  Name:
Address:  
  Address:
City:  
State: Zip: City:
Telephone: (            ) State: Zip:
QTY. ITEM # DESCRIPTION PRICE TOTAL
         
         
         
         
         
         
         
         
1    Free Gift  ($50.00 or more before shipping & tax) FREE FREE
Add totals from this page and any additional pages..............SUBTOTAL
Shipments to Nevada  - 7.75%..............SALES TAX
Shipping charge from chart below.................SHIPPING
Add subtotal, sales tax, and shipping.......ORDER TOTAL		  
 
 
 
SHIPPING CHART
up to $20.00................add $6.00
$20.01 to $30.00.........add $6.75
$30.01 to $40.00.........add $7.50
$40.01 to $50.00.........add $8.50
$50.01 to $70.00........add $10.00
$70.01 to $100.00.....add $12.00
$100.01 to $150.00...add $14.00
$150.01 to $200.00...add $16.00
$200.01 or more........add $18.00
For shipments to Alaska and
Hawaii see our "Shipping"
page for rates.

- Credit Card Information  -
      Visa, MasterCard, Discover, AmEx
  _________________________________
Card Number
_______/_______
Expiration Date (month/year)
___________
3 or 4 digit code from back or front of card
 ______________________________
Name of Cardholder
  or enclose check or money order made payable to:
  Products for Seniors. (Sorry, no COD orders)
If your purchase is a GIFT (  )

Mail to:
Products for Seniors
850 S Boulder Hwy  Ste 171
Henderson NV  89015