Nature'sAlternatives.com
Credit Card Payment by Fax
Authorization Form
Fax#: 1-877-FAX-8080 1-877-329-8080
International Fax: 1-623-321-9977

Please Print Legibly (Address must be billing address for your credit card. If shipping address is different, you can also supply that information.)

Name (as it appears on the credit card)
Address Line 1
Address Line 2 (optional)
City	State/Prov./Prefecture	Postal Code
Country (if not USA)
E-mail Address (needed for order confirmation)	Home Phone (        )	Office Phone (        )
Credit Card Number with Security Code	Card (Visa, MC, Discover, Amex, Diners, Carte Blanche, JCB)	Expiration Date
Name of Recipient (if different, optional)
Shipping Address (if different, optional)
Shipping Address Line 2 (if different, optional)
City	State/Prov./Prefecture	Postal Code
Country (if not USA)

I have read and agree to the following terms:

1. I understand that my order will be processed by Nature'sAlternatives.com resulting in a reference to Nature'sAlternatives.com on my credit card statement.
2. International Orders will be charged the cost of shipping in addition to the product cost.

X_____________________________________________________ Date_____________________________
Member's Signature (must match signature on file with your financial institution)

Please fill in the items you wish to order. Please be sure to include an e-mail address above so that you will receive your order confirmation.

Item	Description	Quantity	Unit Price	Subtotal
	Coupon #: _____________________		-$
Comments:			TOTAL: