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Order Form
Order Date:
Customer Name:
Shipping Address:
Hostess Name:
City:
State:
E-mail Address:
Telephone:
Item
Payment Method
Zip Code:
Description
Credit Card Number
Qty.
Exp. Date
Price
CVC Code
Total
Total
Signature (My signature authorizes Regenova, Inc. to charge my credit card for this order).
Host Rewards
Hostess Gift (orders do not count towards Party totals)
Host Rewards (-)
Name on Credit Card:
Subtotal
Billing Address if different from above:
Sales Tax
Consultant Contact Information:
Shipping/Handling
*S/H Tax
(if applicable)
Grand Total
Thank you for your order. Please contact your Consultant with any discrepancies within ten (10) days of receiving your
order. For all other inquiries please contact customer service at www.customerservice@Allurica.com