Credit Card Payment Form

 9454 Wilshire Blvd | Suite M-4
Beverly Hills, CA 90212
Phone: (310) 277-3436 | Toll Free: (800) 272-3436 | Fax: (310) 277-7120
www.Diennet.com | [email protected]
PAYMENT FORM
NAME: _____________________________________________________________
EMAIL ADDRESS: ____________________________________________________
Quantity
Product
3- month supply
6-month supply
Rush order charge
Price
Amount
$540.00
$1,080.00
$50.00
TOTAL:
NOTE: Orders will be charged in the full amount at time of order, but will be delivered in 3month increments.
PAYMENT METHOD:
 Check or money order made payable to DIENNET
(Returned checks are subject to a service charge for the greater of $15 or maximum allowed by state law.)
Charge my:
 Visa
 Mastercard
 Discover
 American Express
Card #:
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Expiration Date:
__ __ / __ __
Cardholder Name: ___________________________________________________________________
BILLING ADDRESS
Address: ____________________________________________________________________________
City: ____________________________________ State: _______________ Zip: _________________
Phone: (________) _________ - _____________
SIGNATURE: __________________________________________ Date: ________________________