Please print and complete this order form.
Hair By Mail
"Ready Made" Hair Replacement Order Form
Make checks payable to - New Look Hair Replacements
Mail your order to:
2114 N. Flamingo Rd, PMB #183, Pembroke Pines, FL 33028
Call Toll Free - 877-886-9045
Name ___________________________________
Date _________________
Address _________________________________
City __________________________ State__________ Zip Code________ Country_________
Area Code and Phone Number (____)______________ E-Mail Address__________________________
Wearers Name or Initials_____________
Model number ___________________________________________________________________________
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Hair Type Desired: Human Hair___ Synthetic Fiber___
Match color to hair samples? Yes___ No___
Scotch Tape Large Hair Samples in appropriate boxes.
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Special Requests: ________________________________________________________________________
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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.
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To Pay By Credit Card - Visa____  MasterCard____  Amex____  Discover____ Call Me ____

Exact Name on Card__________________________

Number____________________________  Expiration______ Verification Code ______

Signature_________________________    Date__________________