Order Form

Note: This is not a secure server and I would suggest filling in this form, print it and fax it to me or contact me by phone.

Telephone number: 02 6686 2877

Fax number 02 6686 2942

Note: The ointment is unavailable until further notice.

 
Product Selection:
  Qty  Description
  Horse Itch Ointment 500g x 1 ........... $35.00
  Horse Itch Ointment 500g x 2 to 4....... $30.00 ea.
  Horse Itch Ointment 500g x 5 or more.... $25.00 ea.
  Disposable gloves SMALL x 10 pairs .......$5.00
  Disposable gloves MEDIUM x 10 pairs.......$5.00.
  Disposable gloves LARGE x 10 pairs .......$5.00
Shipping Charges at cost based on weight and destination
Delivery Information:

       Name: 
    Company: 
  Address 1: 
  Address 2: 
       City:  State: 
  Post Code:  Country: 

Voice Phone: 
        Fax: 
      Email: 
 Billing Information:

 Cheque or money order. 

    Credit Card: 
    Card Number:  Exp:  (MM/YY)
Cardholder Name: