Testosterone-Rx® - Fax Order Form



Please print this form, enter the required information and fax to:

Austin Research Order Processing Department
(410) 374-8087


ORDERING OPTIONS

  The following are pricing options for Testosterone-Rx® (please circle one):

      Maryland residents please add 6% sales tax.  All prices are in U.S. Dollars.


BILLING INFORMATION

  FULL NAME: ____________________________________________________

  BILLING ADDRESS: ______________________________________________

  CITY, STATE, ZIP: _______________________________________________

  COUNTRY/PROVINCE: ___________________________________________

  TELEPHONE NUMBER: ___________________________________________

  EMAIL ADDRESS: _______________________________________________
  Note: Billing name and address must match the information on your credit card account exactly or it may not be accepted.


SHIPPING INFORMATION

Is your billing address different from your desired shipping address? If so, please enter your billing address above and your shipping address below.

If your billing and shipping address are the same, you may leave this area blank.


  SHIP-TO NAME: _________________________________________________

  SHIPPING ADDRESS: _____________________________________________

  CITY, STATE, ZIP: _______________________________________________

  COUNTRY/PROVINCE: ___________________________________________


CREDIT CARD INFORMATION

  SELECT CARD TYPE:          VISA     MASTERCARD     DISCOVER     AMERICAN EXPRESS

  CREDIT CARD NUMBER: ________________________________________________________

  CARD EXPIRATION DATE: (month/year) ___________________________________________

  CVV2 or CID (3 or 4 digit security code): __________________________________________
   IMPORTANT: THE SECURITY CODE IS A REQUIREMENT. WE MUST HAVE THIS CODE IN ORDER TO PROCESS YOUR ORDER.
   VISA/MC/DISCOVER:  Visa, MC and Discover all use 3 digit codes located on the back of the card, following the credit card number.
   AMERICAN EXPRESS: American Express uses a 4 digit code located on the front of the card, separate from the credit card number.

  ORDER AMOUNT: (6 choices - circle one)                    $74.95    $145.95    $201.00     $268.00    $335.00    $402.00

  TOTAL AMOUNT: (order amount + S&H)                      $ _____________________________________

CUSTOMER AUTHORIZATION

I hereby certify that I am the authorizing card holder of this account. I understand that I will be billed for the total amount calculated above (order amount plus shipping, if applicable). I understand that the name appearing on my credit card billing statement will be either "Austin Research Institute via InternetSecure" or "PAYPAL AUSTINRESEA".


  CARDHOLDER SIGNATURE: ___________________________________________

  This text must be present on order form:         


PLEASE FAX THIS COMPLETED FORM TO (410) 374-8087

In most cases, your order will be shipped within 48 hours of receipt of payment.

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