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Mail Order Form

Please fill out this form completely, then click on the "Print Order" button below. Sign the completed form and mail it to us. Once your order arrives we will email you with confirmation that your order was received. If you have any questions please Contact Us.

(Please Note, this form will NOT send information over the internet)

Purchaser Information

Name:

Address:

City:

State:

Zip:

E-Mail Address:

Day Phone:

Please Use Format: xxx-xxx-xxxx

Website Ordered From:

Shipping Information If Different

Name:

Address:

City:

State:

Zip:

Order Information
Original DermaTend®	$49.95	Qty:
DermaTend® Ultra Kit	$69.95	Qty:
2 DermaTend® Ultra Kit	$79.95	Qty:

Please Select The Appropriate S&H Charges
Tax (NV. Residents Only (7.375%)
Total Order

Payments by Check or Money Order must be made payable to

Solace International

Signature:___________________________________Date:_________________

Print Name: __________________________________________

Please fill out this form completely, then click on the "Print Order" button.

Sign the completed order form and and mail it to us at:

Solace International, Inc.

80 Continental Drive, Ste 101

Reno, NV, 89509