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 send total payment of charges at time of ordering. Make checks payable to "New Look Hair Replacements". Credit cards will be charged 50% at time of order and the balance when shipped. ---------------------------------------------------------------------------- To Pay By Credit Card - Visa____ MasterCard____ Amex____ Discover____ Call Me ____ Exact Name on Card__________________________ Number____________________________ Expiration______ Verification Code ______ Signature_________________________ Date__________________