Resperin Order Form: United States

Just fill in the required information, print and mail or fax.

Mail to:    Resperin™ Canada Ltd.

                420 Erb St. W. Suite 5-209

                Waterloo, Ontario, Canada, N2L 6K6

Fax:        1 (519) 725 4864

Name:              

Email:               

Address:    

City:                    State:   

Zip:                     Phone: 

Product Request:    1 Bottle Resperin's Caisse Formula Tea - $65.00 2 Bottles Resperin's Caisse Formula Tea - $130.00 3 Bottles Resperin's Caisse Formula Tea - $195.00 4 Bottles Resperin's Caisse Formula Tea - $260.00 5 Bottles Resperin's Caisse Formula Tea - $325.00  

(All orders are processed in US funds)

Payment Method:    Cash     Visa    Master Card    Money Order

If paying with Visa or Master card, fill in the following additional information.

Card #                        Expiration:    mm yy

After printing this page, click here to return to the order page, or visit our home page.