Name_________________________________________
Date__________________________________________
Address_________________________________________________________________________________
City_______________________________ State__________ Zip Code____________ Country____________
Area Code and Phone Number (______)______________ E-Mail Address____________________________
Wearers Name or Initials_____________
Model Number ____________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Hair Type Desired: Human Hair_____ Synthetic Fiber_____
Match color to System? Yes___ No___ Scotch Tape Large Hair Samples in appropriate boxes below. (How to take hair samples)
 |
FRONT . . . . |
TEMPLE . . . |
BACK . . . . |
Special Requests_________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Quantity Ordered ________
$_______ Price of First System
$_______ Price of Second System $_______ Price of Third System $_______ Miscellaneous supplies (print form) $_______ Add $50.00 each for 28-day rush charges $_______ Shipping charges $_____ Total Charges |
$_______ Add $13.40 Ea. for UPS Ground shipping*. *Overnight shipping is additional - call for quote. |
-----------Credit card balance will be charged when the order is shipped.---------------------
Credit Card Payment - Visa____ MasterCard____ Amex____ Discover____ Call Me____
Exact Name on Card_____________________________________________________________
Number______________________________ Expiration _________ Verification Code _______
Signature___________________________________________ Date______________________