PAYMENT OPTIONS


PRINT OUT THIS PAGE AND FAX OR POST TO:

Therapeutic Back Support Systems (NZ)Ltd.


P O Box 300 287
Albany
Auckland
New Zealand
Phone : +64 9 476 4927 / 8
Fax : +64 9 476 4928 / 7
Mobile : 021 992509
Freephone : 0800 379 429
E-mail :mailto:therapeutic@ww.co.nz

Contact Person:________________________________________________

Delivery Address:_______________________________________________

Postal Address: ________________________________________

________________________________________________________

Phone : __________________________Fax:_________________________

Email :_______________________________________________________


I have deducted the Discount allowable for people with Fibromyalgia
and I understand you will donate a portion of this sale
to New Zealand Fibromyalgia Research


I wish to pay $________________ for my attached order by:

Cheque Enclosed     ...........................
Credit Options     ........................... Please contact me.
Mastercard       ...........................
Visa        ...........................

My Credit card Number is:    .....................................................................................................

Cardholders Full Name : ___________________________________________________________________

Signature:____________________________________________

Expiry Date : ______/______





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