FAX Order Form

Merry Clinic MAIL/FAX Order Form

To place an order, please print this page and fax or mail your order.Click here for our policy.Use your BACK button to access the previous page.

Tel: 888-880-1499 (inside US/Canada) or 650-588-8335 Fax: 650-588-2544
MAIL Address: Merry Clinic, 370 San Bruno Ave West, Suite F, San Bruno, CA 94066

Sold To: (If paying by credit card, note your name and address as it appears on file with your credit card company.)

Name:_________________________________
Address:______________________________
____________________________________
City:_________________________________
State: ______ Zip: ________________
Daytime Phone: ______________________
Email: _______________________________

Ship To: Please fill in information below if the shipped to address is different.

Name: _____________________________
Address:____________________________
__________________________________
City:_____________________________
State: _____ Zip: _________________
Country: _______________

Daytime Phone: ___________________

ITEMS ORDERED:

Item Name	Qty	Price Each	Total Price

METHOD OF PAYMENT

o Money Order (Payable to Merry Clinic. No Cash or Personal Check)
oAmerican Express oMastercard oVisa oDiscover

Credit Card Number :____________________

Name On Card :____________________
Expiration Date :________________________
Signature : ____________________________

Merchandise Subtotal
State Sales Tax (California only) (See Box "A" below)
Standard Shipping & Handling (See box "B" below)
TOTAL

A: STATE SALES TAX INFORMATION:
We are required by law to collect sales tax on shipments to the state of California. Our Tax rate is 8.25%.

B: STANDARD SHIPPING

Delivery Location	Shipping Cost
US	$8.95
Canada	$20.00
Other Country	$45.00