Quite Healthy Online Ordering

Mail/Fax Order Form (for U.S. orders)

To order by mail, send this form with your payment to:
Quite Healthy Technologies, 5448 Apex Peakway #303, Apex, NC 27502

To order by fax, fill out this form and fax it to: (919) 387-3762

All information below is required:

Name (Please Print)
Address
City		State
Zip	Phone
E-Mail Address

Item Description	Price	Qty	Ext. Price
1. Weight-By-Date Basic Download	$21.95
2. Weight-By-Date Pro Download	$39.95
3. Weight-By-Date Pro CD-ROM Delivery	$49.95
4. Weight-By-Date Mobile Download	$19.95
5. Weight-By-Date Mobile CD-ROM Delivery	$24.95
Shipping and Handling for CD-ROMs Required only if you ordered products 3 or 5 above. All shipping is done via UPS Ground (delivery within 2-5 business days).	$5.95	1
Total Amount Enclosed

Payment Method (circle): CASH / CHECK / MONEY ORDER /
VISA / MC / DISCOVER / AMERICAN EXPRESS

Please Make check or money order payable to "Quite Healthy Technologies"
Note: There will be a $32.00 charge assessed for all returned checks

Please add the following information for credit card orders:

Card# _________________________________ Exp. Date: ____ / ____

EXACT Name on Card: _________________________________________

Signature ____________________________________________________