Active Liquid Minerals & Vitamins

ACTIVE
Liquid Minerals

PHONE ORDERS
888-839-6002 (PST)

AUTOSHIP FORM

FREE SHIPPING (USA Only)
Starts with your 2ND ORDER.

NOTE: MINIMUM QUANTITY OF TWO (2) TO QUALIFY

NOTE: Due to the high cost of shipping, if you fail to notify us that you want to cancel your 'Auto-ship' and we ship your order, then shipping costs and a 15% restocking fee will be deducted for any returned items.

Do You Have Your Customer #

Billing

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Credit Card:
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Expiration Date: (MM/YY)
Verification Number:	(3 or 4 digit # on the back of the card) Click Here For Explanation

Name/Company:
Street Address:
Address (Cont):
City:
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Country:
Phone:
Email:

Check here if billing & shipping are the same.

SHIPPING ADDRESS (If different to Billing Address?)

Name/Company:
Street Address:
Address (Cont):
City:
State:
Zip/Postal Code:
Country:
Phone:

Active Calcium Pack	Quantity:
Active Health Pack	Quantity:
Active Liquid Minerals	Quantity:
Active Liquid Vitamins	Quantity:
Active Liquid Calcium	Quantity:
Active Immune Support	Quantity:
Neptune Krill Oil	Quantity:
Active Skin Care	Quantity:

'AUTOSHIP' Ship Date:

Please enter the shipping frequency by month
(e.g. Every month, Every 3 months, etc)

Send my 'Autoship' NOW:
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Comments:

NOTE: Due to the high cost of shipping, if you fail to notify us that you want to cancel your 'Auto-ship' and we ship your order, then shipping costs and a 15% restocking fee will be deducted for any returned items