Healthy Highway Order Form

18251 Hickory Ridge, Fenton, MI  48430   
Phone:  810-629-9923 

DATE  _______________________                                                                 

Name  ______________________________________________________________________________________

Street Address _______________________________________________________________________________

City  _____________________________________________   State / Prov. ___________  ZIP  ______________

Country _____________________________________________________________________________________

Phone Number   _________________________________ 

EMAIL (If wanting email shipment notification)_______________________________________________________ 

No.

Qty

Description

Number

or Size

Price Each

Price Total

1

 

 

 

 

 

2

 

 

 

 

 

3

 

 

 

 

 

4

 

 

 

 

 

5

 

 

 

 

 

6

 

 

 

 

 

 

Text Box: Phone Orders:  MasterCard, Visa & Discover. 

Fax or Mail Orders:   
Visa, MasterCard, Discover, Money Orders & Personal Checks.

Personal Checks and eCheck’s usually take about 3 or 4 days to clear the bank before we can ship.

 

Sub-Total

 

 

6% Tax

(Mich. Only)

 

 

Shipping

 

 

Handling

 

 

TOTAL

 

Special shipping instruction’s (if any) _______________________________________________

Credit Card Number ____________________________________________________________

Expiration Date _____________________    3-Digit Security Code on back ____________

Credit Card Information (if different than shipping address):

Name: ____________________________  Address: _____________________________________ ZIP: _____________


 

 Make checks and money orders payable to:  Brad Austin