RevitaBust Order Form

Mail / FAX Order Form
*Print this page, fill out all information, and send this form by mail or fax to:
Cosmeceutical Technologies

FAX: 310-822-0650

Customer Information

Name:
Address:

City:
State:	Zip:
Country:
Phone:
Email:

Payment Method

Select one
	Money Order / Cashiers Check (Payable to CTI in US$ only)
	Visa / MasterCard / American Express (circle one)
	Credit Card Number:
	Expiration Date:	/ Signature: _________________________

Select Products

	Buy 2 bottles of RivitaBust Get 1 bottle Free (Three Month Supply )	$119.80
	Buy 3 bottles of RivitaBust Get 2 bottles Free (five Month Supply )	$179.85
	Buy 5bottles of RivitaBust Get 4 bottles Free (nine Month Supply )	$299.75
	Single bottle of RivitaBust	$59.95
	Special Bonus Offer: Perfect Woman Firming & Toning Lotion	$24.95
	Bonus Offer: Detoxify	$19.95

	Subtotal:	$.
	Subtotal:	$.
	Shipping (US orders $9.95, international orders $24.95)	$.
	Grand Total:	$.

Mail Order Form to: (make the check payable to CTI)

Cosmeceutical Technologies

or Fax This Form to:

310-822-0650