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)_______________________________________________________ 

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: _____________

eCheck:   Check Number  ___________      Bank Routing Number ( 9 digits) __________________________________

Account Number ____________________________________    

Bank Name __________________________________ 

Bank Address: __________________________________________________________  ZIP: _____________

Bank Phone # _____________________________

EXAMPLE of Numbers on Personal Check

Routing Code

Bank Account Number