Name ___________________________________
Date _________________
Address _________________________________
City __________________________ State__________ Zip Code________ Country_________
Area Code and Phone Number (____)______________ E-Mail Address__________________________
Wearers Name or Initials_____________
Model number ___________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Hair Type Desired: Human Hair___ Synthetic Fiber___
Match color to hair samples? Yes___ No___
Scotch Tape Large Hair Samples in appropriate boxes.
 |
. . . |
. . . |
. . . |
Special Requests: ________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Quantity Ordered _____
Price of First System
_____
Price of Second System
_____
Price of Third System
_____
Miscellaneous Supplies
_____
Total System Charge
_____
----------------------------------------------------------------------------
Please include
US$16.40 for UPS-Ground shipping. UPS 2nd Dair Air and Overnight shipping is additional.
Hair Replacements. Credit cards will be charged 50% at the time of the order
and the balance when the order is shipped.
To Pay By Credit Card - Visa____ MasterCard____ Amex____ Discover____ Call Me ____
Exact Name on Card__________________________
Number____________________________ Expiration______ Verification Code ______
Signature_________________________ Date__________________