Amethyst BioMat and AlkaLife Water System Online Order Form

Harmonious Being, LLC Amethyst BioMat Order Request

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

Street Address*
Street Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Country

E-mail Address*
E-mail Address*

Home Phone*
Home Phone*

Business Phone

Social Security or Federal ID #*
Social Security or Federal ID #*

Amethyst BioMat Professional

	$1350
	$100 Professional Discount (you must fax a copy of your professional certificate or license to 925-253-0149 in order to receive this discount)

Shipping & Handling

$60

Quantity

Amethyst/Tourmaline Pillow

$250

Shipping & Handling

$20

Quantity

Alka-Life Water System

$1500

Shipping & Handling

$50

Quantity

Distributor Kit

$27.95

Shipping & Handling

$15

Please Add and Total Your Order *
Please Add and Total Your Order *

Select Credit Card Type*
Select Credit Card Type*

Credit Card Number
(no dashes or spaces)*
Credit Card Number
(no dashes or spaces)*

Expiration Date (mm/yy)*
Expiration Date (mm/yy)*

Security Code*
Security Code*

Name as it appears on the card*
Name as it appears on the card*

Signature*
Signature*

Checking this box serves as an authorized signature to process your order. Your Credit Card will be charged for the amount entered above. If there are any discrepancies you will be contacted before your order is processed.

Preferred method of commmunication

Additional Comments

Please enter the word that you see below.

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