Herbal Pack Order Form

Print out your Submission Confirmation and enclose with your payment
Please make Check or Money Order Payable to:
ALPHAPAC, Inc.
2607 S. Woodland Blvd. #222
DeLand, FL 32720

Purchase Options:

Quantity:	LUMBAR PAC (11"x 6") $29.75 for 1 $28.50 Each - 2 to 4 $27.88 Each - 5 to 9 $25.35 Each - 10 / Case Add $5.25 S&H - Continental US Only If Different we will contact you with Shipping Costs.
Quantity:	ALPHA PAC (8"x 6") $14.95 for 1 $12.50 Each - 2 to 4 $10.00 Each - 5 + Add $4.00 S&H- Continental US Only If Different we will contact you with Shipping Costs.

*First name*
*Last name*
*Address*
*City*
*Zip*
*(UPS REQUIRES) Phone #*
*E-Mail Address*

*Payment Options:*	Check or Money Order
	Credit Card
*Credit Card #:*
*Expires:*
Shipping Address: Your Order will be Shipped to the Above Address Unless Noted Here: