RxDirect2u.com Mail Order Form

First Name:
  
Last Name:
 

Street Address:
(Orders to P.O.
Boxes will be Delayed.)

  
City:  
Zip/Postal Code:
 		 
Country:  
Phone:  
**e-mail:
(**see note below)		  

Item Quantity Price Check Box
Regular Vaporizer 1 $ 59.99
2 $ 99.99
3 $ 139.99
Deluxe (North American) 1 $ 69.99
2 $ 119.99
3 $ 159.99
Deluxe (220V) 1 $ 69.99
2 $ 119.99
3 $ 159.99
Vapo-to-Go (12V DC) 1 $ 59.99
2 $ 99.99
3 $ 139.99
Vaporizer AC/DC Combo
(Vapo-to-go + Regular)		 1 $ 99.99
 
TOTAL OF ITEMS  $
 
Plus Shipping & Handing:   
 North America $ 12.99
 International $ 19.99
    
GRAND TOTAL (US Funds) $
    *Note: All Prices are in US funds. 

-------------------- cut along dotted line. mail in top half of form -------------------------

How to use this Order Form:

1. Print out this page
2. Make cheque or money order payable to: RxDirect2u
3. Mail it with your payment to...

7004575 Canada Ltd.
Box 95056,
Kingsgate RPO,
Vancouver, BC
V5T 1W0
Canada

Payment Options:
Please make postal or money orders payable to RxDirect Inc. Orders paid by personal check will be delayed until payment has been cleared through our bank.
In order to ensure quick shipping, your money order or bank draft  MUST be made payable to: 7004575 Canada Ltd.

** Confirmation via e-mail:
Your order will be confirmed by e-mail, and you will receive a unique tracking number to trace your order.
RxDirect


Please double check your order:

1. Is your information filled out correctly.
2. Have you totalled your order correctly.
3. Have you included your Payment.

Thank you for choosing RxDirect2u.com!