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ORDER-FORM
PRODUCTS ARE GUARANTEED BY THE MANUFACTURER
WE SHIP IN PLAIN PACKAGING
FOR PRIVACY AND DISCRETION
PLEASE PRINT CLEARLY
FULL NAME (AS IT APPEARS ON CREDIT CARD
FULL NAME _____________________________________
AMX CC# __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
DELIVERY ADDRESS _____________________________________
STREET
CITY STATE ZIP
___ XXTRA-CLEAN

___ READY-CLEAN

___ FAST-FLUSH

___ CONSTANT
CLEANSE
$54.95

$39.95

$34.95

$24.99
$51.95

$36.95

$31.95

$21.99
UNITS
ADD $3.95 PER BOTTLE FOR S&H
ADD $2.50 PER BOX FOR S&H
TOTAL $
.
MONEY ORDER OR CERTIFIED CHECK ONLY PAYABLE TO COAST TO COAST IF NOT USING AMERICAN EXPRESS CARD

C&C/DRUG TEST
4074 STE.3A
GLEN ALLEN, VA 23060
FILL IN ORDER- FORM AND MAIL TO: