www.lapislazuliworld.com

Lapis Lazuli World  -  2637 E Atlantic Blvd #29155, Pompano Beach, FL 33062 USA   -  Fax 305-359-9273
Print this form and use it for reference when placing your order by mail or FAX it to us.


(A) Ship To: (name and address)
Fed Ex and UPS can not ship to 
Post Office Boxes or apo addresses
(B) Bill To: (please fill in bill to information if
this differs from your shipping address)
Name: _____________________________ Name:  ________________________________
Address: ___________________________ Address: _______________________________
Address: ___________________________ Address: _______________________________
City:    ____________    State:  __________
Province:______ Zip:  _______  Country: ______
City:  ___________    State: _________
Province:________ Zip:  ________ Country: ________
Telephone: ______________________ Daytime Telephone: ______________
Email (if any): ____________________ Email (if any): ____________________
  Above information must match your issuing banks records when using a credit card.

   (C) List of Items:

Item #: Item Name: Quantity: Size (if applicable) Price per Item: Total:
           
           
           
           
           
           
           
           
           
           
           
        Subtotal  $  

(D) Totals & Shipping:


Carrier Delivery Time Order Amount Continental USA Puerto Rico, Hawaii and Canada International Orders
 First Class Mail (tracking through http://www.usps.com/) 8 - 15 Business days 0 to $149.99 $6.95 $8.95 Not available
$150.00 to $499.99 FREE $12.95 Not available
$500 and up FREE $17.95 Not available

Next Day Air

(tracking through http://www.fedex.com/ or http://www.ups.com/)

2-3 Business Days 0 to $149.99 $23.75 $26.75 $32.75
$150.00 to $499.99 $26.75 $28.75 $36.75
$500.00 and up $28.75 $30.75 $38.95
   
   
  Merchandise Total: $
  (Our minimum order is 25.00, not including the cost of shipping.)
 
  Shipping (choose one)
       Certified First Class Mail:   __________
       Next Day Delivery:  _________  
  TOTAL: $

(E) Method of Payment:
 
___ Money Order (payable to "Andes Organics")
___ American Express _____  Mastercard  ____ Visa  ____Discover ____ Diners ______ Carte Blanche ____ JCB

Credit card # _______________________________ Exp. date: ______/_______ (Month/Year)
CVV:  _______   

I agree to pay the above total amount according to card issuer agreement   X_________________________Date_______

 

Back to www.lapislazuliworld.com