ORDER FORM

Item Price Quantity Amount
Chemo Hair Re-Growth RX 8 oz (240ml) $39.99 ______ ___________
SUBTOTAL ___________
Sales Tax (GA Residents please add 7%) ___________
Shipping/Handling please add $4.99 for US Orders,
$25.00 Flat Fee for International Orders.
___________
TOTAL ___________
Name: _______________________________________________________
Address: _______________________________________________________
City, ST,  ZIP: _______________________________________________________
Phone Number: ______________________
Email Address: ________________________________
How did you hear about Chemo Hair Re-Growth RX?

______________________________________________________________________________________

Payment Method:    Cashier's Check Money Order

Please mail this form, with your payment to:
2004 Chemo Hair Re-Growth RX, Inc.
1654 Watson Boulevard
Warner Robins, GA  31093