Fax to: 1-941-485-3145 Or, Mail it to:
SHC C/O LipoRidPM.com
8437 Tuttle Ave. #403
Sarasota, FL 34243

Name: _________________________ City: _________________________
Email: _________________________ State: _________________________
Address: _________________________ Country: _________________________
Phone: (____) ______ - ____________ Zip: _________________________
1 Bottle LipoRid PM™ Sleep Aid Sleeping Pills _____ @ $29.95 = $ __________
2 Bottles LipoRid PM™ + 1 FREE Bottle _____ @ $59.90 = $ __________
3 Bottles LipoRid PM™ + 2 FREE Bottles _____ @ $89.85 = $ __________
5 Bottles LipoRid PM™ + 4 FREE Bottles _____ @ $149.75 = $ __________
SUB TOTAL = $ __________
Shipping & Handling = $ __________
TOTAL = $ __________

Standard Delivery via US Postal Service
   FREE Orders over $85; $9.95 Orders under $85; $12.95 Hawaii, Alaska, Puerto Rico, US Virgin Isles, Guam
US Domestic Express Delivery (Not available to APO, FPO or PO boxes)
   $39.95 USPS Express Mail Delivery (Overnight Most Locations)
International Delivery
   $29.95 USPS Priority Mail International Delivery (Avg. 6-10 Business Days); $99.95 USPS Global Air Mail Delivery (Avg. 3-5 Business Days)

( ) I am enclosing a check or money order for $____________
Please note: If you are paying by check you must make it payable to SHC, LLC and mail it in. We do not accept checks by fax.

( ) I want to charge this purchase to my Credit Card

Credit Card (check one):

VISA MasterCard American Express Discover

Card Number: _________________________

Expiry Date: _________ Signature: _________________________

I authorize SHC, LLC to charge $____________ to my credit card for the purchase (and shipment) of the above products.

Note: If you are using a credit card charges will show up on your statement under SHC, LLC which is our parent company. All orders will be shipped within 48 hours of receipt. Orders accompanied by checks will be held until cleared.