Please print, fill in (black ink only)
and mail or fax this form to:
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MAIL  Human Excellence      
  7514 Girard Avenue #116      
  La Jolla, CA  92037   PHONE  (619) 379-9367

Name: 		     Phone:  (          )
Address:      Fax:  (          )
City:      Country:   
State:      E-mail:   
ZIP:      Web Address:   

Item #
Description
Quantity
Price		 Item Total
(QTY x Price)
         
         
         
         
         
Shipping    
Tax     
Total    

ţ Payment choice:
          ¨ Check or Money Order (payable to: Human Excellence)

          ¨ VISA®   ¨ MASTERCARD®  ¨ American Express®

Card # __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __  Exp. ___ / ___ (e.g. 09/07)

Authorized Signature ___________________________

Card Billing Address (if different than mailing address)

Address _________________________   City __________________

State ______   Country _____________     Zip __________-_______