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Ultra-Balm Wholesale Order Form

 

 

Please fill out this form completely, BOLD fields are required!
(DO NOT HIT "ENTER" OR "RETURN" - THIS WILL SEND THE FORM!)

Date:

Store/Company Name: 

Authorized Buyer:    

Referred By:     
(There is no additional cost with referral.)

Phone Number:  Fax Number: 

Email Address:    

Website:

Type Of Outlet:         

SHIP TO ADDRESS

Ship To Name:   

Street Address:    

City:      State:  Zip Code: 

ORDER DETAILS

Select original citrus scented or unscented:

Jars:    Tubes:
S/H Not Included In Above Prices
All Wholesale orders are shipped UPS Ground.
 ORDER 50 CASES OF ANY MIX & GET FREE SHIPPING!

Suggested retail price is $39.95 per Jar & $15.00 per Tube.
(Wholesale unit costs: $19.95 per jar & $7.99 per tube.)

POINT OF SALE PROMOTION REQUEST
(Please check all you wish to receive.)

Counter Table Tent  Window Sign 8.5 x 11  Window Sign 8.5 x 14

Wall Sign 8.5 x 11 Wall Sign 8.5 x 14

Additional Comments:

PAYMENT INFORMATION

Payment Method: (please check one) Visa MasterCard Amex Discover

Credit Card Billing Name:

Credit Card #:

Expiration Date:  /  CVV:  Billing Zip Code:

Tax Exempt Resale #:

**Please note: without a resale certificate number on file you will be charged tax in addition on your order.


                

 
Unauthorized use is a willful infringement upon rights under 17 U.S.C. Section 101 et seq.
You will be held liable for statutory damages as high as $150,000 for each occurrence as set forth in Section 504 (c)(2) therein.
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