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Fax Order Form

Fax Order Instructions
1. Print this page.
2. Fill out form as completely as possible. Make sure to include a phone number so we can contact you with any questions.
3. Fax to 773-989-8108 or Mail with Check to Merz Apothecary, 4716 N. Lincoln Ave, Chicago, IL 60625

BILL TO
Name:
Address:
City:
State:
Zip:
Phone:
Email:

SHIP TO
Name:
Address:
City:
State:
Zip:
Phone:
Email:

Credit Card # :

Signature :

CVV :

Exp Date :

Qty	Product Name	Unit Price	Total









		Items total:
		* Sales tax:
		Shipping:**
		Order total:

* IL residents pay 2% on all medicinal items, 9% on books and cosmetic items

** Standard UPS Ground Shipping (3-7 business days):
$6.00 plus $.50 cents for each item

Priority UPS 2nd Day Air Shipping (2 business days after order is processed):
$13.00 plus $1.00 for each item

UPS Next Day Saver Airmail (delivered by end of day Next Business Day after order is processed):
$25.00 plus $1.00 for each item

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