Fax order form: Fax to 012 361 0061

If you wish to order via fax:

Please print out this page

Fill in your order and your credit card details, or pay by EFT and fax us the proof of payment. Our bank details....

Fax it to our offices.

Name and surname
Credit card type	Visa / MasterCard / Amex / Diners (Circle the type)
Card number
CCV number (3 digit number on the back of your card on the signature strip)	(If you are paying by direct transfer into the ABSA account, please fax proof of payment)
Expiry date	Month (............) Year (............)
E-mail address
Telephone number
Full street or postal address (including Province, postal code.	line 1
	line 2
	line 3
Signature as on card: .....................................	Province:
	Postal code:
	(Postal code is also used for courier parcels, as courier companies use the code to sort their parcels)

Description			Quantity	Total
Instant Eye Lift Gel	R	190.00
Postage / Courier				R 35.00
If we are supplied with a street address your parcel will be sent by courier. If we are supplied with a postal box address, your parcel will be sent via the Post Office Speed Courier Services to the Post Office counter. See more information on South African delivery...			Total	R