Prostivia™ - Mail Order Form



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

Austin Research Institute
Order Dept # VIA
P.O. Box 522
Hampstead, MD 21074
USA


ORDER SIZE OPTIONS

  The following are pricing options for Prostivia™ (please circle one):

      Maryland residents please add 6% sales tax.  All prices are in U.S. Dollars.
      Each bottle of Prostivia™ contains a 30 day supply.


PAYMENT OPTIONS

  We accept the following forms of payment (U.S. funds only):

   Note: We do not accept personal checks or COD's.


  Please make your money order payable to: Austin Research Institute


CUSTOMER SHIPPING INFORMATION

  FULL NAME: ____________________________________________________

  STREET ADDRESS: _______________________________________________

  CITY, STATE, ZIP: _______________________________________________

  COUNTRY/PROVINCE: ___________________________________________

  TELEPHONE NUMBER: ___________________________________________

  EMAIL ADDRESS: ______________________________________________

   Note: Your daytime telephone number is needed in the event the carrier has to contact you regarding delivery. Your email address is needed in the event that we must contact you regarding your order.
  All of your information will remain completely confidential and will not be sold or given to anyone. Maryland residents please add 6% sales tax. All prices are in U.S. Dollars.


AGE VERIFICATION

  I hereby certify that I am at least 18 years of age.


  CUSTOMER SIGNATURE: ____________________________________________


MAIL THIS COMPLETED FORM (WITH PAYMENT) TO:

Austin Research Institute
Order Dept # VIA
P.O. Box 522
Hampstead, MD 21074
USA

Your order will be shipped within 24 hours of receipt of payment.

Copyright © 2004 - Present. Austin Research Institute. All Rights Reserved.