Fax Order Form

Roberta S. Herzog Enterprises, Inc.
ORDER FORM
by mail or fax

PRINT and FAX this Page to:
828-338-0186

Name ______________________________________________

Address____________________________________________

City, State, Zip_______________________________________

Daytime Phone: ( ......) _________________________________
Evening Phone: ( ......)__________________________________

Item or services: ______________ @ ___________ $ ______________

Number of books _______@____________$ ___________

Number of The Akashic Record CDs ______@ $_______

Shipping and Handling..................................... $ ____________
International orders shipping cost will be quoted by Roberta
Total Enclosed................................................ $ ____________

Please enclose check payment method:

____Check ____Money Order

____VISA, ____MasterCard

Credit Card # _______________________________________
3 digit auth. code on the back of card ________

Expiration Date: _____________________________________

Please print card holder's name: __________________________

Sign card holder's name: ________________________________

Billing address, if different from above:

Additional Shipping Names and Addresses:

Name______________________________________________
(Item to be shipped ____________________________)
Address____________________________________________
City, State, Zip_______________________________________
Daytime Phone: ( ......) _________________________________

Name______________________________________________
(Item to be shipped______________________________)
Address____________________________________________
City, State, Zip_______________________________________
Daytime Phone: ( ......) _________________________________

Name______________________________________________
(Item to be shipped _____________________________)
Address____________________________________________
City, State, Zip_______________________________________
Daytime Phone: ( ......) _________________________________

PRINT and FAX this Page to:
828-338-0186

E-mail: iamlux@aol.com

Roberta S. Herzog Enterprises, Inc.
P.O. Box 278
Fletcher, NC 28732 USA