Complete All Information, Print Form, Then Mail This Form To:

Glutimax.Com - PO BOX 16764 - Rochester, NY  14616

Please Make All Payments Payable to: "CleavOnline"

Shipping Information

First and Last Name:

Shipping Address:
Including complete 
street address, city, 
state and zip code

Phone Number:

E-Mail Address:

Credit Card Information (If Paying By Credit/Debit/Pre-Paid/Gift Card)

Visa/MasterCard/Amex/Discover#:

Visa/MasterCard/Amex/Discover Expiration Date:

CIV Code On Back of Card:

Your Glutimax Order Contents (CHECK ONE)

Check:Glutimax - 1 Jar $39.99 + $9.95 S&H Add $9.95 S&H
Check:Glutimax - 2 Jars $74.99 + $9.95 S&H Add $9.95 S&H
Check:Glutimax - 3 Jars $104.99 + $9.95 S&H Add $9.95 S&H
Check:Glutimax - 4 Jars $129.99 + $9.95 S&H Add $9.95 S&H
Check:Glutimax - 5 + 1 FREE $149.99 + $9.95 S&H Add $9.95 S&H
Check:More than 6? # of units x $24.99 each Add $9.95 S&H

Additional Shipping

Upgrade to OverNight S&H (USA ONLY)
ADD $20 Extra
Check:

NON-USA Order. Additional S&H fee
ADD $35 Extra
Check:

Total Cost (US DOLLARS ONLY)

Product Cost + S&H