dht•Sensor Request Form 
[ Please print and then fax or mail ]


NAME:___________________________________________________

ADDRESS:________________________________________________ APT # ________

CITY:_____________________________________ STATE:_____ ZIP:_____________

DAYTIME PHONE #:______________

 

PRODUCTS REQUESTED:

NUMBER REQUESTED  PRICE EACH TOTAL FOR PRODUCT 
____ STARTER KIT(S)@  $______ $_________ 
____ ENZYME COMPLEX @ $______ $_________ 
____ SHAMPOO @ $______ $_________ 
____ CONDITIONER @ $______ $_________ 
____ VITAMINS @ $______ $_________ 
   TOTAL CHARGE $_________ 

IF YOU ARE FAXING OR MAILING-IN YOUR ORDER WE WILL NEED:

YOUR CREDIT CARD NUMBER_______________________________________________

EXP. DATE________________


--------------------------------------------------------------------------------