Fax / Mail Order Form
Mail to InspiredLiving.com, PO Box 388, Dundee OR 97115 or fax to 503-554-0840
Money Orders, Cashier's Checks and Preprinted USA Checks ONLY payable to InspiredLiving.com.

Customer Shipping Information

Company

 

First Name

 

Ship Address

 

Middle Initial

 

Ship Address

 

Last Name

 

City

 

Phone (required)

 

State

 

Email Address

 

Zipcode

 

Date Ordered

 

Special Instructions

 

Order Information

Qty

Description of Products

Unit $

Total $

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Call 866-875-4386 for shipping charges

Shipping

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We accept credit cards, preprinted checks, money orders, cashier's checks

Amount Due

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Payment Information

Payment: (circle one): Visa  MasterCard  Discover  American Express Check Money Order

_______________________________________ Credit Card #      ___ / ___ Expiration Date (mm/yy)

_____ 3 Digit Verification Code (on the back of the card, in the signature field, it's the last 3 digits on the right)

_______________________________________________________ Name on Card (if different from above)

_______________________________________________________ Billing Address (if different from shipping)

Please send me the selected products. I understand there is a charge for returned checks and unauthorized credit card charge backs. I authorize InspiredLiving.com and its agents, including financial institutions, to initiate debit entries for the products ordered plus shipping where applicable. 

_____________________________________________________ Signature