Web Infusions - Printable Order Form Mail:  Web Infusions – 6004 Riverside Dr. BLDG - B, Irving, TX 75039   or Fax:: (501) 639-8639
SHIP To:
	NAME:
	ADDRESS:
	CITY:                                                   STATE:             ZIP:
EMAIL:
BILLTo:                                                                               _____CHECK HERE IF SAME AS ABOVE
	NAME:
	ADDRESS:
	CITY:                                                   STATE:             ZIP:
PAYMENT INFO:
	__ Check or money order payable to Web Infusions is enclosed.
	Charge to:    __Visa, __Amex __ MasterCard, Card Number:                                                      Exp Date: Signature:

QTY	Item	Description	Price Each	Total Price
Merchandise Total
Shipping costs will be added at time of shipping
TOTAL AMOUNT DUE: