Cool Blue Gel Mail Order Form

CoolBlueGel.com Mail Order Form

525 E. 5^th St., Bloomsburg, PA 17815 USA www.CoolBlueGel.com

Email: DNLLCUSA@aol.com

Customer Assistance: 1-570-380-1320

YOUR INFORMATION:

Name:	Date:
Billing Address:
Billing City, State, Zip:	Email:
Phone:	Fax:
Shipping Address:
Shipping City, State, Zip:	**REQUIRED:
Method of Payment: ____VISA _____Mastercard _____AmExp _____Discover $$$	“V”# (back of card)________
Credit Card No.: Signature:	Exp. Date: /
*Make Checks Payable to: Dromaius Novae’ LLC _____Check Enclosed*

CODE	PRODUCT	PRICE EA.	QTY.	TOTAL
CGB4 – 1	4 oz. Cool Blue Gel – 1 Bottle	$19.95 USD		$
CBG4 – 2	4 oz. Cool Blue Gel – 2 Bottles – SAVE $15	$34.90 USD		$
CBG4 – 3	4 oz. Cool Blue Gel – 3 Bottles – SAVE $30	$49.85 USD		$
CBG4 – 4	4 oz. Cool Blue Gel – 4 Bottles – SAVE $45	$64.80 USD		$
CGBMS	4 oz. Cool Blue Gel – 1 Bottle – MONTHLY SHIPMENT CLUB – Each month hereafter, you will only be charged $14.95 per 4 oz. Bottle. Can Cancel at any time. Must purchase first bottle @ $19.95.	$14.95 USD		$
Sign to join	Monthly Shipment Club:______________________

QUESTIONS? Call 570-380-1320

Order Total	$
Shipping/Handling = $6.95 (Canada $14.95)	$
PA Residents Sales Tax – None for Analgesics	$
	$
TOTAL PAYMENT ENCLOSED	$

PRICES SUBJECT TO CHANGE WITHOUT NOTICE. All Prices in U.S. Dollars. Export Orders = Additional S/H Charges.

*We will notify you promptly if your item is backordered and will ship as soon as available.

Thank you for your order! We sincerely appreciate it. Visit us on the internet at www.CoolBlueGel.com.