Drop Ship Order From

							www.yourorganzabag.com                                      DROP SHIPPING                                 Date:
P.O. Box 661510, Arcadia, CA 91066-1510                                                                   P.O. #:

Sold to:                                                    Ship to:

Email:                                                      Email:
Phone:                                                      Phone:
Fax:                                                        Fax:
      *********************************************** FAX THIS FORM TO: 1 - 626 - 226 - 4088 *************************************************
Qty               Item #            Description                                    Color                  Unit Price            Line Total




DROP SHIPPING DROP SHIPPING DROP SHIPPING DROP SHIPPING DROP

                                                                                                        Subtotal $                               -

  Billing Information * required                                                                       Sales Tax
  1. First Name :                                                              10% Discount when you order $200+
  2. Last Name:                                                                        Shipping and Handling Fee                           $7.50
  3. Card Type:                                                                                             Total
  4. Credit Card Number:
  5. Expiration Date of Credit Card:
  6. Billing Address:                                                               Authorized by                                Date